1
|
Ceasovschih A, Alexa RE, Șorodoc V, Balta A, Constantin M, Coman AE, Petriș OR, Stătescu C, Sascău RA, Onofrei V, Diaconu AD, Morărașu BC, Rusu-Zota G, Șorodoc L. Persistent Gastrointestinal Bleeding after Aortic Valve Replacement in Heyde's Syndrome. J Clin Med 2024; 13:4515. [PMID: 39124781 PMCID: PMC11313494 DOI: 10.3390/jcm13154515] [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: 05/14/2024] [Revised: 07/10/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Heyde's syndrome (HS) represents an association between aortic stenosis and intestinal angiodysplasias, and it has been demonstrated that acquired von Willebrand disease plays a pivotal role in the pathophysiology of this syndrome. In patients with HS, von Willebrand factor deficiency represents an additional risk factor, further contributing to the risk of bleeding and anemia. We present the case of an 86-year-old patient diagnosed with HS and von Willebrand deficiency in 2018. Four years prior, the patient underwent surgical aortic valve replacement. Since then, she has been receiving chronic oral anticoagulation therapy with a vitamin K antagonist. The patient was admitted to the Internal Medicine Clinic due to semi-solid dark stools, diffuse abdominal pain, and asthenia. Upon examination, the patient presented with an altered general status and clinical signs suggestive of anemia. Laboratory findings revealed anemia with elevated INR and aPTT values. Colonic angiodysplasias were identified during a colonoscopy, although no sources of active bleeding were detected. On the 9th day of hospitalization, the patient experienced an episode of lower gastrointestinal bleeding. The pharmacological management was adjusted, and argon plasma coagulation was recommended. Following treatment of the angiodysplastic lesions, the patient's clinical evolution was favorable, with the correction of the anemia.
Collapse
Affiliation(s)
- Alexandr Ceasovschih
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Raluca-Elena Alexa
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Victorița Șorodoc
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Anastasia Balta
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Mihai Constantin
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Adorata Elena Coman
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Ovidiu Rusalim Petriș
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Cristian Stătescu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Department of Cardiology, “Prof. Dr. George I.M. Georgescu” Cardiovascular Diseases Institute, 700503 Iasi, Romania
| | - Radu A. Sascău
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Department of Cardiology, “Prof. Dr. George I.M. Georgescu” Cardiovascular Diseases Institute, 700503 Iasi, Romania
| | - Viviana Onofrei
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Department of Cardiology, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Alexandra-Diana Diaconu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Bianca Codrina Morărașu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| | - Gabriela Rusu-Zota
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Department of Pharmacology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Laurențiu Șorodoc
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (M.C.); (A.E.C.); (O.R.P.); (C.S.); (R.A.S.); (V.O.); (A.-D.D.); (B.C.M.); (G.R.-Z.); (L.Ș.)
- Second Internal Medicine Clinic, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania; (R.-E.A.); (A.B.)
| |
Collapse
|
2
|
Hamiko M, Gerdes L, Silaschi M, Seidel H, Westhofen P, Kruppenbacher J, Hertfelder HJ, Oldenburg J, Bakhtiary F, Velten M, Oezkur M, Duerr GD. Investigation of von Willebrand factor multimer abnormalities before and after aortic valve replacement using the Hydragel-5 assay. Thromb Res 2024; 241:109094. [PMID: 38991494 DOI: 10.1016/j.thromres.2024.109094] [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: 02/08/2024] [Revised: 06/24/2024] [Accepted: 07/05/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Severe aortic stenosis (sAS) is associated with acquired von Willebrand syndrome (AVWS) by loss of high-molecular-weight multimers (HMWM) of von Willebrand factor (VWF), potentially resulting in perioperative bleeding. Analysis of VWF multimers remains challenging. Recently, the new, rapid Hydragel 5 assay has been developed, using electrophoretic protein separation for dividing VWF-multimers into low (LMWM), intermediate (IMWM), and HMWM, the hemostatically active part of VWF. Here, we evaluated its impact on predicting blood loss in presence of AVWS after surgical aortic valve replacement (SAVR). METHODS We prospectively examined 52 patients (age: 68 ± 7 years; 54 % male) admitted to SAVR. They were divided in two groups (A: normal VWF, n = 28; B: abnormal VWF, n = 24, defined as VWF-activity/antigen (VWF:Ac/Ag)-ratio < 0.7 and/or HMWM loss). Blood samples and echocardiographic data were collected before, seven days and three months after SAVR. Blood loss and transfusions were recorded. RESULTS Baseline characteristics and clinical data were similar in both groups. HMWM loss was present in 38.5 % of all patients. HMWM, the VWF:Ac/Ag- and HMWM/(IMWM+LMWM)-ratios were significantly decreased preoperatively in group B but normalized after SAVR. Bleeding, re-thoracotomy and transfusion rates were comparable. HMWM loss was inversely correlated with the peak aortic gradient (Pmax) and positively with the aortic valve area (AVA), while HMWM/(IMWM+LMWM)-ratio negatively correlated with the mean aortic gradient (Pmean). CONCLUSION HMWM and HMWM/(IMWM+LMWM)-ratio inversely correlate with severity of AS and normalize after SAVR. The Hydragel-5 assay's might be valuable for routine diagnostics to assess bleeding risk and postoperative normalization of AS and VWF abnormalities in SAVR patients.
Collapse
Affiliation(s)
- Marwan Hamiko
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Lena Gerdes
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Miriam Silaschi
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Holger Seidel
- Center for Bleeding Disorders and Transfusion Medicine, (CBT), Bonn, Germany
| | - Philipp Westhofen
- Center for Bleeding Disorders and Transfusion Medicine, (CBT), Bonn, Germany
| | | | - Hans-Joerg Hertfelder
- Center for Bleeding Disorders and Transfusion Medicine, (CBT), Bonn, Germany; Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Markus Velten
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mehmet Oezkur
- Department of Cardiovascular Surgery, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
| | - Georg Daniel Duerr
- Department of Cardiovascular Surgery, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
| |
Collapse
|
3
|
Perduca V, Bouaziz O, Zannis K, Beaussier M, Untereiner O. Can machine learning provide preoperative predictions of biological hemostasis after extracorporeal circulation for cardiac surgery? J Thorac Cardiovasc Surg 2023:S0022-5223(23)01019-X. [PMID: 37931798 DOI: 10.1016/j.jtcvs.2023.10.062] [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: 07/11/2023] [Revised: 10/12/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES The goal of this study was to improve decision making regarding the transfusion of patients at the end of extracorporeal circulation for cardiac surgery through machine learning predictions of the evolution of platelets counts, prothrombin ratio, and fibrinogen assay. METHODS Prospective data with information about patient preoperative biology and surgery characteristics were collected at Institut Mutualiste Montsouris Hospital (Paris, France) for 10 months (n = 598). For each outcome of interest, instead of arbitrarily choosing 1 machine learning algorithm, we trained and tested a variety of algorithms together with the super learning algorithm, a state-of-the-art ensemble method that aggregates all the predictions and selects the best performing algorithm (total, 137 algorithms). We considered the top-performing algorithms and compared them to more standard and interpretable multivariable linear regression models. All algorithms were evaluated through their root mean squared error, a measure of the average difference between true and predicted values. RESULTS The root mean squared error of the top algorithms for predicting the difference between pre- and postoperative platelet counts, prothrombin ratio, and fibrinogen assay were 38.27 × 10e9/L, 8.66%, and 0.44 g/L, respectively. The linear models had similar performances. CONCLUSIONS Our machine learning algorithms accurately predicted prothrombin ratio and fibrinogen assay and less accurately platelet counts. As such, our models could provide an aid-decision tool for anesthetists in an operating room; future clinical trials addressing this hypothesis are warranted.
Collapse
Affiliation(s)
| | | | - Kostantinos Zannis
- Department of Cardiac surgery, Institut Mutualiste Montsouris, Paris, France
| | - Marc Beaussier
- Department of Anesthesiology, Institut Mutualiste Montsouris, Paris, France
| | - Olivier Untereiner
- Department of Anesthesiology, Institut Mutualiste Montsouris, Paris, France.
| |
Collapse
|
4
|
Goltstein LCMJ, Rooijakkers MJP, Hoeks M, Li WWL, van Wely MH, Rodwell L, van Royen N, Drenth JPH, van Geenen EJM. Effectiveness of aortic valve replacement in Heyde syndrome: a meta-analysis. Eur Heart J 2023; 44:3168-3177. [PMID: 37555393 PMCID: PMC10471563 DOI: 10.1093/eurheartj/ehad340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 03/22/2023] [Accepted: 04/13/2023] [Indexed: 08/10/2023] Open
Abstract
AIMS Heyde syndrome is the co-occurrence of aortic stenosis, acquired von Willebrand syndrome, and gastrointestinal bleeding. Aortic valve replacement has been demonstrated to resolve all three associated disorders. A systematic review and meta-analysis were performed to obtain best estimates of the effect of aortic valve replacement on acquired von Willebrand syndrome and gastrointestinal bleeding. METHODS AND RESULTS A literature search was performed to identify articles on Heyde syndrome and aortic valve replacement up to 25 October 2022. Primary outcomes were the proportion of patients with recovery of acquired von Willebrand syndrome within 24 h (T1), 24-72 h (T2), 3-21 days (T3), and 4 weeks to 2 years (T4) after aortic valve replacement and the proportion of patients with cessation of gastrointestinal bleeding. Pooled proportions and risk ratios were calculated using random-effects models. Thirty-three studies (32 observational studies and one randomized controlled trial) on acquired von Willebrand syndrome (n = 1054), and 11 observational studies on gastrointestinal bleeding (n = 300) were identified. One study reported on both associated disorders (n = 6). The pooled proportion of Heyde patients with acquired von Willebrand syndrome recovery was 86% (95% CI, 79%-91%) at T1, 90% (74%-96%) at T2, 92% (84%-96%) at T3, and 87% (67%-96%) at T4. The pooled proportion of Heyde patients with gastrointestinal bleeding cessation was 73% (62%-81%). Residual aortic valve disease was associated with lower recovery rates of acquired von Willebrand syndrome (RR 0.20; 0.05-0.72; P = 0.014) and gastrointestinal bleeding (RR 0.57; 0.40-0.81; P = 0.002). CONCLUSION Aortic valve replacement is associated with rapid recovery of the bleeding diathesis in Heyde syndrome and gastrointestinal bleeding cessation. Residual valve disease compromises clinical benefits.
Collapse
Affiliation(s)
- Lia C M J Goltstein
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Maxim J P Rooijakkers
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marlijn Hoeks
- Department of Haematology, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Wilson W L Li
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marleen H van Wely
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Laura Rodwell
- Department of Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Section Biostatistics, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Erwin-Jan M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| |
Collapse
|
5
|
Ramesh P, Kanagalingam S, Zargham Ul Haq FNU, Victory Srinivasan N, Khan AI, Mashat GD, Hazique M, Khan KI, Khan S. Acquired Von Willebrand Deficiency in Adults With Aortic Stenosis: A Systematic Review. Cureus 2022; 14:e28879. [PMID: 36225403 PMCID: PMC9541123 DOI: 10.7759/cureus.28879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Von Willebrand factor (VWF) deficiency is associated with bleeding complications. The congenital type of Von Willebrand disease(VWD) is a very well-known bleeding disorder and sometimes may be associated with life-threatening hemorrhage. This systematic review is aimed at gathering further knowledge regarding the pathology of an acquired VWD form within a population of patients with aortic stenosis (AS) by shortlisting quality articles on this theme, through the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 guidelines. High shear stress caused by the stenotic valve cleaves VWF multimers, causing a relative state of deficiency. The condition returns to baseline immediately following surgical replacement of the valve. Results across eight studies reviewed by a majority concluded that in an AS patient with bleeding, the most likely cause is an acquired deficiency of VWF, associated with factors influencing blood flow and caused by the in-situ valve. However, several studies suggested otherwise/were misclassifications. This review highlighted the relationship between AS and acquired VWF deficiency and should be foreseen as an adverse complication, attracting further research and future theragnostic strategies for this condition.
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Musilanga N, Hongli Z, Hongyu C. Reappraising the spectrum of bleeding gastrointestinal angioectasia in a degenerative calcific aortic valve stenosis: Heyde’s syndrome. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00046-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The occurrence of bleeding gastrointestinal angioectasia in elderly patients with degenerative calcific aortic stenosis is one of the most challenging clinical scenarios. A number of studies have shown that this clinical phenomenon is known as Heyde’s syndrome.
Main body of the abstract
The pathogenesis of Heyde’s syndrome is mainly due to the loss of high-molecular-weight von Willebrand factor (HMW vWF) multimers, as a consequent fragmentation of HMW vWF multimers as they pass through the stenosed aortic valve leading to acquired von Willebrand syndrome type IIA. Aortic valve replacement has proven to be a more effective management approach in the cessation of recurrent episodes of gastrointestinal bleeding.
Short conclusion
Physicians should have a high index of suspicion when dealing with elderly patients with established aortic stenosis presenting with iron deficiency anemia or unclear gastrointestinal bleeding. Parallel consultations between different specialties are essential for appropriate management.
Collapse
|
8
|
Zahid S, Ullah W, Khan MU, Abbas S, Ud Din MT, Uddin MF, Inayat A, Ubaid A, Salman F, Thakkar S, Salama A, Khan MZ. Trends, predictors, and outcomes of major bleeding after transcatheter aortic valve implantation, from national inpatient sample (2011-2018). Expert Rev Cardiovasc Ther 2021; 19:557-563. [PMID: 33926363 DOI: 10.1080/14779072.2021.1924678] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Major bleeding remains one of the most frequent complications seen in transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate outcomes, trends, and predictors of major bleeding in patients undergoing TAVI. METHODS We utilized the National Inpatient Sample (NIS) data from the year 2011 to 2018. Baseline characteristics were compared using a Pearsonχ2 test for categorical variables and Mann-Whitney U-Test for continuous variables. A multivariable logistic regression model was used to evaluate predictors of major bleeding. Propensity Matching was done for adjusted analysis to compare outcomes in TAVI with and without major bleeding. RESULTS A total of 215,938 weighted hospitalizations for TAVI were included in the analysis. Of the patient undergoing the procedure, 20,102 (9.3%) had major bleeding and 195,836 (90.7%) patients did not have in-hospital bleeding events. Patients in the major bleeding cohort were older and had greater female gender representation. At baseline patients with thrombocytopenia (Odds Ratio [OR], 1.47[confidence interval (CI), 1.36-1.59]), colon cancer (OR, 1.70[CI, 1.27-2.28]), coagulopathy (OR, 1.17[CI, 1.08-1.27]), liver disease (OR, 1.31[CI, 1.21-1.41]), chronic obstructive pulmonary disease (OR, 1.29[CI, 1.25-1.33]), congestive heart failure (OR, 1.12[CI, 1.08-1.16]), and end-stage renal disease (ESRD) (OR, 1.47[CI, 1.38-1.57]) had higher adjusted rates of major bleeding. The percentage of adjusted in-hospital mortality (14.4% vs. 4.2%, P < 0.01) was significantly higher in the major bleeding group Patients with major bleeding had higher median cost of stay ($235,274 vs. $177,920) and length of stay (7 vs 3 days). CONCLUSION In conclusion, we report that mortality is higher in patients with major bleeding and that baseline comorbidities like ESRD, liver disease, coagulopathy and colonic malignancy are important predictors of this adverse event.
Collapse
Affiliation(s)
- Salman Zahid
- Department of Medicine, Rochester General Hospital, Rochester,NY,USA
| | - Waqas Ullah
- Department of Medicine, Abington Jefferson Health, PA, USA
| | - Muhammad Usman Khan
- Department of Cardiology, Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, WV, USA
| | - Sakina Abbas
- Department of Medicine, Dow Medical College, Karachi, PK
| | | | | | - Arslan Inayat
- Department of Medicine, Internal Medicine, University at Buffalo, Catholic Health System, Buffalo, NY, USA
| | - Aamer Ubaid
- Department of Medicine, Internal Medicine, University of Missouri- Kansas City, Kansas City, MO
| | - Fnu Salman
- Department of Medicine, Mercy Health St. Vincent Medical Center, Toledo, USA
| | | | - Amr Salama
- Department of Medicine, Rochester General Hospital, Rochester,NY,USA
| | - Muhammad Zia Khan
- Department of Medicine, West Virginia University, Medicine, Morgantown, WV, USA
| |
Collapse
|
9
|
Casonato A, Galletta E, Cella G, Barbon G, Daidone V. Acquired von Willebrand Syndrome Hiding Inherited von Willebrand Disease Can Explain Severe Bleeding in Patients With Aortic Stenosis. Arterioscler Thromb Vasc Biol 2020; 40:2187-2194. [PMID: 32640909 DOI: 10.1161/atvbaha.120.314656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Aortic stenosis may be complicated by an acquired von Willebrand syndrome that rarely causes significant bleeding, raising the question of why it does so in a few cases. To seek an explanation, we studied 5 severe bleeder aortic stenosis patients in a cohort of 49 patients, using the flowchart for inherited von Willebrand disease. Approach and Results: All 5 patients were lacking in large and intermediate VWF (von Willebrand factor) multimers, 3 had reduced plasma and platelet VWF levels, and none showed PFA100 closure. Two patients (those with most multimers missing) also had a short VWF half-life. Genetic analyses on the 3 patients with reduced platelet VWF levels revealed that one carried both the c.1164C>G and the c.7880G>A mutations, and another carried the c.3390C>T mutation, while the third had one of the 2 VWF alleles relatively less expressed than the other (25% versus 75%). No genetic alterations emerged in the other 2 patients. Successful replacement of the stenotic aortic valve, performed in the 2 patients with VWF mutations, did not correct their abnormal VWF multimer picture-unlike what happened in the aortic stenosis patients without bleeding symptoms. CONCLUSIONS Our findings suggest that acquired von Willebrand syndrome can develop in patients with hitherto-undiagnosed inherited von Willebrand disease. Since von Willebrand disease is the most common bleeding disorder, this possibility should be considered in aortic stenosis patients-especially those with a more severe bleeding history and more disrupted VWF laboratory patterns-because they risk hemorrhage during aortic valve replacement.
Collapse
Affiliation(s)
- Alessandra Casonato
- From the Department of Medicine, First Chair of Internal Medicine (A.C., E.G., G.B., V.D.), University of Padua Medical School, Italy
| | - Eva Galletta
- From the Department of Medicine, First Chair of Internal Medicine (A.C., E.G., G.B., V.D.), University of Padua Medical School, Italy
| | - Giuseppe Cella
- Department of Cardiac, Thoracic and Vascular Sciences (G.C.), University of Padua Medical School, Italy
| | - Giovanni Barbon
- From the Department of Medicine, First Chair of Internal Medicine (A.C., E.G., G.B., V.D.), University of Padua Medical School, Italy
| | - Viviana Daidone
- From the Department of Medicine, First Chair of Internal Medicine (A.C., E.G., G.B., V.D.), University of Padua Medical School, Italy
| |
Collapse
|
10
|
Pre-procedural abnormal function of von Willebrand Factor is predictive of bleeding after surgical but not transcatheter aortic valve replacement. J Thromb Thrombolysis 2020; 48:610-618. [PMID: 31359325 PMCID: PMC6800844 DOI: 10.1007/s11239-019-01917-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Both transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) have been proven to effectively correct von Willebrand Factor (vWF) pathologies, however there is limited data simultaneously comparing outcomes of both approaches. We prospectively enrolled patients with severe aortic stenosis referred for TAVI (n = 52) or SAVR (n = 48). In each case, vWF antigen (vWF:Ag), vWF activity (vWF:Ac) and activity-to-antigen (vWF:Ac/Ag) ratio were assessed at baseline, 24 h and 72 h after procedure. VWF abnormalities were defined as reduced vWF:Ac/Ag ratio (< 0.8). Bleeding events in both arms were classified according to Valve Academic Research Consortium (VARC-2) definitions. Overall, there was no difference between patients referred for TAVI and SAVR in vWF:Ac (1.62 ± 0.52 vs 1.71 ± 0.64; p = 0.593), vWF:Ag (1.99 ± 0.81 vs 2.04 ± 0.81; p = 0.942) or vWF:Ac/Ag ratio (0.84 ± 0.16 vs 0.85 ± 0.12; p = 0.950). Pathological vWF:Ac/Ag ratio was found in 20 (38%) TAVI and 15 (31%) SAVR patients (p = 0.407). Normalization of vWF:Ac/Ag ratio at day 3 after procedure was achieved in 19 (95%) TAVI and 13 (87%) SAVR patients (p = 0.439). Similar prevalence of major or life-threatening bleedings (MLTB) after TAVI and SAVR in entire groups was observed (19% vs. 23%, p = 0.652). VWF abnormalities were associated with higher incidence of MLTB in SAVR (53% vs 9%, p < 0.001), but not TAVI (15% vs. 22%, p = 0.132). Accordingly, in receiver-operating characteristic curve analysis vWF:Ac/Ag ratio < 0.8 showed significant sensitivity and specificity for predicting MLTB in SAVR group (AUC 0.735, 95% CI 0.538–0.931, p = 0.019). We proved that abnormal function of vWF is corrected successfully after both TAVI and SAVR, but vWF abnormalities are predictive of MLTB only in surgical patients.
Collapse
|
11
|
Kibler M, Marchandot B, Messas N, Labreuche J, Vincent F, Grunebaum L, Hoang VA, Reydel A, Crimizade U, Kindo M, Hoang MT, Zeyons F, Trinh A, Petit-Eisenmann H, De Poli F, Leddet P, Duhamel A, Jesel L, Ohana M, Susen S, Ohlmann P, Van Belle E, Morel O. Primary Hemostatic Disorders and Late Major Bleeding After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2019; 72:2139-2148. [PMID: 30360823 DOI: 10.1016/j.jacc.2018.08.2143] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/13/2018] [Accepted: 08/06/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Periprocedural and late (>30 days) bleedings represent major complications after transcatheter aortic valve replacement and have been identified as potential areas for improved patient care. OBJECTIVES The authors sought to evaluate the impact of ongoing primary hemostasis disorders on late major/life-threatening bleeding complications (MLBCs). METHODS Bleedings were assessed according to the VARC-2 (Valve Academic Research Consortium-2) criteria. Closure time of adenosine diphosphate (CT-ADP), a surrogate marker of high molecular weight von Willebrand multimers proteolysis was assessed 24 h after the procedure. Ongoing primary hemostasis disorder was defined by a CT-ADP >180 s. RESULTS Among 372 patients who survived at 30 days, MLBCs occurred in 42 patients (11.3%) at a median follow-up of 383 days (interquartile range: 188 to 574 days). MLBCs were mainly of gastrointestinal origin (42.8%) and were associated with increased overall mortality (hazard ratio [HR]: 5.66; 95% confidence interval [CI]: 3.10 to 10.31; p < 0.001) and cardiac mortality (HR: 11.62; 95% CI: 4.59 to 29.37; p < 0.001). A 2.5-fold elevation of MLBCs could be evidenced in patients with a CT-ADP > 180 s (27.4% vs. 11.5%; p < 0.001). Multivariate regression analysis identified paravalvular leak (PVL) (HR: 6.31; 95% CI: 3.43 to 11.60; p < 0.0001) and CT-ADP > 180 s (HR: 3.08; 95% CI: 1.62 to 5.81; p = 0.0005) as predictor of MLBCs. CONCLUSIONS MLBCs after transcatheter aortic valve replacement are frequent and associated with an increased morbidity and mortality. PVL and CT-ADP >180 s were identified as strong predictors for MLBCs. These findings strongly suggest that persistent HMW defects contribute to enhanced bleeding risk in patients with residual PVL.
Collapse
Affiliation(s)
- Marion Kibler
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Benjamin Marchandot
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Nathan Messas
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Julien Labreuche
- Department of Biostatistics, Centre Hospitalier Universitaire, Lille, France
| | - Flavien Vincent
- CHU Lille, Institut Coeur-Poumon, Cardiology, Lille, France; University of Lille, INSERM U1011 - EGID, Institut Pasteur de Lille, Lille, France
| | - Lelia Grunebaum
- Department of Haemostasis, Centre Hospitalier Universitaire, Strasbourg, France
| | - Viet Anh Hoang
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
| | - Antje Reydel
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Ulun Crimizade
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Michel Kindo
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Minh Tam Hoang
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Floriane Zeyons
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Annie Trinh
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Hélène Petit-Eisenmann
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Fabien De Poli
- Department of Cardiology, Centre Hospitalier de Haguenau, Haguenau, France
| | - Pierre Leddet
- Department of Cardiology, Centre Hospitalier de Haguenau, Haguenau, France
| | - Alain Duhamel
- Department of Biostatistics, Centre Hospitalier Universitaire, Lille, France
| | - Laurence Jesel
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France; UMR 1260 INSERM Nanomédecine Régénérative, Université de Strasbourg, Strasbourg, France
| | - Mickael Ohana
- Department of Radiology, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Sophie Susen
- University of Lille, INSERM U1011 - EGID, Institut Pasteur de Lille, Lille, France; CHU Lille, Hematology Transfusion, Lille, France
| | - Patrick Ohlmann
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Eric Van Belle
- CHU Lille, Institut Coeur-Poumon, Cardiology, Lille, France; University of Lille, INSERM U1011 - EGID, Institut Pasteur de Lille, Lille, France. https://twitter.com/Eric_Van_Belle
| | - Olivier Morel
- Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France; UMR 1260 INSERM Nanomédecine Régénérative, Université de Strasbourg, Strasbourg, France.
| |
Collapse
|
12
|
Berger J, Schwartz J, Ramachandran S, Leff JD. Review of von Willebrand Disease and Acquired von Willebrand Syndrome for Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:3446-3457. [PMID: 31570241 DOI: 10.1053/j.jvca.2019.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 08/10/2019] [Accepted: 08/17/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Jay Berger
- Department of Anesthesiology, Montefiore Hospital and Medical Center, Bronx, NY.
| | - Joseph Schwartz
- Department of Anesthesiology, Montefiore Hospital and Medical Center, Bronx, NY
| | | | - Jonathan D Leff
- Department of Anesthesiology, Montefiore Hospital and Medical Center, Bronx, NY
| |
Collapse
|
13
|
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.
Collapse
|
14
|
Brandenburger C, Unislawski V, Budde U, Zittermann A, Gummert J, Knabbe C, Birschmann I. The von Willebrand factor ratio and perioperative bleeding in patients with aortic valve stenosis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019. [DOI: 10.23736/s0021-9509.18.10209-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Von Willebrand factor and the aortic valve: Concepts that are important in the transcatheter aortic valve replacement era. Thromb Res 2018; 170:20-27. [PMID: 30092557 DOI: 10.1016/j.thromres.2018.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 07/17/2018] [Accepted: 07/27/2018] [Indexed: 12/14/2022]
Abstract
Since the approval of the first transcatheter aortic valve replacement (TAVR) device in 2011, this technology has undergone substantial enhancements and exponential growth. However, valve thrombosis and residual paravalvular leaks (PVL) are among the challenges that require further investigation. Recently, monitoring von Willebrand factor (vWF) multimers has emerged as a tool to help evaluate the severity of PVL after TAVR. Following TAVR, vWF large multimers recovery have been documented. The role of large vWF multimers recovery and their interactions with platelets, and the endothelium have not been entirely elucidated. In this review, we discuss vWF synthesis and its role in aortic stenosis. We further provide an overview of the studies that investigated changes affecting vWF multimers following TAVR and the role of HMW vWF multimers monitoring in the determination of PVL severity. We also offer potential future directions for what will be fertile ground for research in this field.
Collapse
|
17
|
Tanaka H, Nagai Y, Kuwabara C, Shimizu R, Umeki A, Yamamoto T. Acquired von Willebrand Syndrome due to Aortic Valve Stenosis in a Case with Antiphospholipid Antibody. Intern Med 2018; 57:1641-1644. [PMID: 29321442 PMCID: PMC6028691 DOI: 10.2169/internalmedicine.9860-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Acquired von Willebrand syndrome (AVWS) is a bleeding disorder caused by an acquired deficiency of von Willebrand factor (vWF). Some patients with AVWS show a low bleeding tendency and are diagnosed by the presence of a mild prolongation of activated partial thromboplastin time (APTT) preoperatively. Another cause of APTT prolongation is the presence of antiphospholipid antibody (aPL). We experienced a case of AVWS due to aortic valve stenosis in a patient with aPL in whom aortic valve replacement surgery was successful with vWF replacement. In patients with AVWS-associated disorders who are identified based on APTT prolongation at the preoperative examination, both vWF and aPL screening tests must be performed.
Collapse
Affiliation(s)
| | - Yurie Nagai
- Department of Hematology, Asahi General Hospital, Japan
| | | | - Ryo Shimizu
- Department of Hematology, Asahi General Hospital, Japan
| | - Akihide Umeki
- Department of Cardiovascular Surgery, Asahi General Hospital, Japan
| | | |
Collapse
|
18
|
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.
Collapse
Affiliation(s)
- Joseph L Blackshear
- Department of Cardiovascular Diseases, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| |
Collapse
|
19
|
Kellermair J, Ott HW, Spannagl M, Tomasits J, Kammler J, Blessberger H, Reiter C, Steinwender C. Characterization of Von Willebrand Factor Multimer Structure in Patients With Severe Aortic Stenosis. Clin Appl Thromb Hemost 2017; 24:496-501. [PMID: 29202604 PMCID: PMC6714650 DOI: 10.1177/1076029617744321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Acquired von Willebrand syndrome (AVWS) associated with severe aortic stenosis (AS) has been frequently subclassified into a subtype 2A based on the deficiency of high-molecular-weight (HMW) multimers as it is seen in inherited von Willebrand disease (VWD) type 2A. However, the multimeric phenotype of VWD type 2A does not only include an HMW deficiency but also a decrease in intermediate-molecular-weight (IMW) multimers and an abnormal inner triplet band pattern. These additional characteristics have not been evaluated in AVWS associated with severe AS. Therefore, we recruited N = 31 consecutive patients with severe AS and performed a high-resolution Western blot with densitometrical band quantification to characterize the von Willebrand factor (VWF) multimeric structure and reevaluate the AVWS subtype classification. Study patients showed an isolated HMW VWF multimer deficiency without additional abnormalities of the IMW portions and the inner triplet structure in 65%. In conclusion, the multimeric pattern of AVWS associated with severe AS does neither resemble that seen in AVWS type 2A nor that seen in inherited VWD type 2A. Therefore, a subclassification into a type 2A should not be used.
Collapse
Affiliation(s)
- Joerg Kellermair
- 1 Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Linz, Austria
| | - Helmut W Ott
- 2 Department of Hemostasis and Transfusion Medicine, Ludwig-Maximilians University, Munich, Germany
| | - Michael Spannagl
- 2 Department of Hemostasis and Transfusion Medicine, Ludwig-Maximilians University, Munich, Germany
| | - Josef Tomasits
- 3 Department of Laboratory Medicine, Kepler University Hospital, Linz, Austria
| | - Juergen Kammler
- 1 Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Linz, Austria
| | - Hermann Blessberger
- 1 Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Linz, Austria
| | - Christian Reiter
- 1 Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Linz, Austria
| | - Clemens Steinwender
- 1 Department of Cardiology and Internal Intensive Medicine, Kepler University Hospital, Linz, Austria.,4 Paracelsus Medical University of Salzburg, Salzburg, Austria
| |
Collapse
|
20
|
Elmariah S, Aledort L, Dlott J, Stelzer P, Halperin J, Kini A, Sharma S, Bander J. Changes in von Willebrand factor-cleaving protease (ADAMTS-13) in patients with aortic stenosis undergoing valve replacement or balloon valvuloplasty. Thromb Haemost 2017; 108:86-93. [DOI: 10.1160/th11-12-0803] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 04/13/2012] [Indexed: 11/05/2022]
Abstract
SummaryIt was the objective of this study to determine whether reduced cleavage of von Willebrand factor (VWF) multimers following aortic valve replacement (AVR) is a consequence of reduced shear stress or postoperative changes in VWF cleavage protease (ADAMTS-13) activity. Aortic stenosis (AS) may be complicated by acquired von Willebrand disease. Aortic valve replacement (AVR) corrects the associated haematologic abnormalities. We enrolled 114 patients with severe AS scheduled for either balloon aortic valvuloplasty (BAV; n=64) or AVR (n=50). Haematologic assessments of VWF levels and activity and ADAMTS-13 were performed before and 24 hours after valve intervention. The VWF:RCo to VWF:Ag ratio, a surrogate for large VWF multimer activity, increased by 37% (p < 0.0001) after AVR and by 10% (p = 0.0002) after BAV. ADAMTS-13 activity significantly decreased after AVR (579 ± 127 to 468 ± 135 ng/ml; p<0.0001), but not after BAV (484 ± 153 to 529 ± 185 ng/ml; p = 0.10). By multivariable analysis, the change in VWF:RCo ratio after AVR was more strongly associated with the fall in ADAMTS-13 than with reduction of valve gradient; whereas the change in gradient better predicted the rise in VWF:RCo after BAV. In conclusion, both BAV and AVR reverse the haematological abnormalities of the acquired von Willebrand syndrome of AS and ADAMTS-13 levels decrease after AVR. These findings suggest that a portion of the haematologic benefit of AVR may be due to a postoperative decline in ADAMTS-13 rather than solely to relief of AS as previously thought.
Collapse
|
21
|
Tjahjadi C, Wee Y, Hay K, Tesar P, Clarke A, Walters DL, Bett N. Heyde syndrome revisited: anaemia and aortic stenosis. Intern Med J 2017; 47:814-818. [DOI: 10.1111/imj.13419] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/22/2017] [Accepted: 02/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Catherina Tjahjadi
- Department of Cardiology; Prince Charles Hospital; Brisbane Queensland Australia
| | - Yong Wee
- Department of Cardiology; Prince Charles Hospital; Brisbane Queensland Australia
| | - Karen Hay
- Department of Statistics; QIMR Berghofer Medical Research Institute; Brisbane Queensland Australia
| | - Peter Tesar
- Department of Cardiac Surgery; Prince Charles Hospital; Brisbane Queensland Australia
| | - Andrew Clarke
- Department of Cardiothoracic Surgery; Prince Charles Hospital; Brisbane Queensland Australia
| | - Darren L. Walters
- Department of Cardiology; Prince Charles Hospital; Brisbane Queensland Australia
| | - Nicholas Bett
- Department of Cardiology; Prince Charles Hospital; Brisbane Queensland Australia
| |
Collapse
|
22
|
Banovic MD. Changing concept in treatment of asymptomatic severe aortic stenosis and normal ejection fraction: time for biomarkers reappraisal. Biomark Med 2017; 11:369-376. [PMID: 28290210 DOI: 10.2217/bmm-2016-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The uncertainty of whether/how to treat asymptomatic patients with isolated severe aortic stenosis and normal left ventricular ejection fraction is one of the most topical in cardiovascular medicine. Recently, the AVATAR trial: first ever randomized trial in the setting of aortic stenosis has been started in an attempt to adequately address this 'burning issue'. In light of this fact it is important to identify biomarkers which might help in risk stratification of these patients, not only in the referring physician's office during a routine exam, but also for preoperative patients scheduled for surgical replacement/transcatheter aortic valve implantation. This report is focusing on novel laboratory parameters which might be helpful in this risk stratification.
Collapse
Affiliation(s)
- Marko D Banovic
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia.,Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
23
|
Frank RD, Lanzmich R, Haager PK, Budde U. Severe Aortic Valve Stenosis. Clin Appl Thromb Hemost 2016; 23:229-234. [DOI: 10.1177/1076029616660759] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aortic valve stenosis (AVS) is the most common valve disease in adults. Severe forms are associated with acquired von Willebrand syndrome (aVWS) with loss of the largest von Willebrand factor (VWF) multimers. Diagnostic gold standard is the VWF multimer analysis. Valve replacement rapidly restores the VWF structure. Uncertainty exists if this effect is permanent and how functional VWF assays perform compared with multimer analysis. We studied 21 consecutive patients with severe AVS before and 6 to 18 months after valve surgery and compared them with 14 controls without valve disease referred for coronary angiography. The VWF multimers, VWF antigen (VWF:Ag), VWF collagen binding capacity (VWF:CB), VWF:CB/VWF:Ag ratio, in vitro bleeding time (PFA-100), factor VIII coagulation activity (FVIII:C), and VWF ristocetin cofactor activity (VWF:RCo) were determined. In all patients with AVS, the large VWF multimers were strongly reduced (56 ± 13% of normal plasma); all controls had normal multimers. The PFA-100 collagen/ADP closure times (coll/ADP CT) were prolonged in patients with AVS compared with the controls (175 ± 56 seconds vs 86 ± 14 seconds, P < .001). The VWF:CB/VWF:Ag ratio was pathological in 20 of the 21 patients but normal in controls. After surgery, the multimers normalized in all patients and coll/ADP CT shortened (pre 184 ± 65 seconds vs post 102 ± 22 seconds; P < .001). The VWF:CB/VWF:Ag ratio strongly improved ( P < .001) and normalized in 14 of 17 patients. In conclusion, all consecutive patients with severe AVS had an aVWS. The combination of coll/ADP CT and VWF:CB/VWF:Ag ratio detected the aVWS in all patients. More than 6 months after valve replacement, the VWF multimers were still normalized in all patients indicating a permanent cure of the aVWS.
Collapse
Affiliation(s)
- Rolf Dario Frank
- Department of Nephrology and Clinical Immunology, University Hospital, RWTH Aachen, Eschweiler, Germany
| | - Regina Lanzmich
- Department of Nephrology and Clinical Immunology, University Hospital, RWTH Aachen, Eschweiler, Germany
| | - Philipp K. Haager
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Ulrich Budde
- Medilys Laboratory, Asklepios Klinik Altona, Hamburg, Germany
| |
Collapse
|
24
|
Kokame K. Subsequent Response of VWF and ADAMTS13 to Aortic Valve Replacement. J Atheroscler Thromb 2016; 23:1141-1143. [PMID: 27476668 PMCID: PMC5098912 DOI: 10.5551/jat.ed055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center
| |
Collapse
|
25
|
Daidone V, Barbon G, Cattini MG, Pontara E, Romualdi C, Di Pasquale I, Hosokawa K, Casonato A. Usefulness of the Total Thrombus-Formation Analysis System (T-TAS) in the diagnosis and characterization of von Willebrand disease. Haemophilia 2016; 22:949-956. [PMID: 27293213 DOI: 10.1111/hae.12971] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The heterogeneity of von Willebrand disease (VWD) makes its diagnosis a difficult task. METHODS We report here on the usefulness of a microchip-based flow-chamber system, the total thrombus-formation analysis system (T-TAS), in the identification and characterization of VWD. Thirty VWD patients and 20 healthy subjects were studied with the T-TAS platelet (PL) and atherome (AR) microchips developed for the in vitro assessment of platelet thrombus formation and fibrin-rich platelet thrombus formation respectively. RESULTS Samples from severe type 1 VWD, characterized by von Willebrand factor (VWF) levels below 10 U dL-1 , failed to occlude either the PL or the AR chip capillaries, while the occlusion times were normal in patients with mild type 1 VWD (VWF above 25 U dL-1 ). PL and/or AR chip occlusion occurred, but took longer than normal, for samples from type Vicenza and type 1 VWD patients, whose VWF levels ranged between 10 and 25 U dL-1 . No PL or AR chip capillary occlusion was seen for samples from patients with type 2A or 2B VWD featuring the absence of large VWF multimers, whereas no abnormalities emerged for type 2B patients with normal multimer patterns. CONCLUSION The T-TAS appears to be sensitive mainly to plasma VWF concentration and the presence of large multimers. Failure of the PL and AR chips to become occluded points to a lack of large VWF multimers, or type 1 VWD with VWF levels below 10 U dL-1 . Although the T-TAS does not assure a precise VWD diagnosis, it does point us in the right direction, and thus seems a useful global preliminary test.
Collapse
Affiliation(s)
- V Daidone
- Department of Cardiologic, Thoracic and Vascular Sciences, Thrombohemorrhagic Disorders Unit, University of Padua Medical School, Padua, Italy
| | - G Barbon
- Veneto Institute of Oncology IRCCS, Familial Cancer Clinic and Oncoendocrinology, Padua, Italy
| | - M G Cattini
- Department of Cardiologic, Thoracic and Vascular Sciences, Thrombohemorrhagic Disorders Unit, University of Padua Medical School, Padua, Italy
| | - E Pontara
- Department of Cardiologic, Thoracic and Vascular Sciences, Thrombohemorrhagic Disorders Unit, University of Padua Medical School, Padua, Italy
| | - C Romualdi
- Department of Biology, University of Padua, Padua, Italy
| | - I Di Pasquale
- Department of Medicine, University of Padua, Padua, Italy
| | - K Hosokawa
- Research Institute Fujimori Kogyo Co., Yokohama, Japan
| | - A Casonato
- Department of Medicine, University of Padua, Padua, Italy
| |
Collapse
|
26
|
Budde U, Scheppenheim S, Dittmer R. Treatment of the acquired von Willebrand syndrome. Expert Rev Hematol 2015; 8:799-818. [DOI: 10.1586/17474086.2015.1060854] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
27
|
Jilma-Stohlawetz P, Quehenberger P, Schima H, Stoiber M, Knöbl P, Steinlechner B, Felli A, Jilma B. Acquired von Willebrand factor deficiency caused by LVAD is ADAMTS-13 and platelet dependent. Thromb Res 2015; 137:196-201. [PMID: 26616301 DOI: 10.1016/j.thromres.2015.11.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/29/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The high shear rates induced by left ventricular assist devices cause acquired von Willebrand disease (aVWD). We hypothesised that an ex vivo model could be established to study whether mechanical shear stress alone causes aVWD or whether this process depends also on the VWF cleavage protein ADAMTS-13 and on platelets. MATERIALS AND METHODS Healthy volunteers and two patients with congenital ADAMTS-13 deficiency donated blood. In vitro closed extracorporeal circuits were established using medically approved left ventricular assist devices (LVAD). VWF multimers were quantified by gel electrophoresis; VWF antigen, ristocetin cofactor activity (VWF:RCo), ADAMTS-13 levels and platelet function were assessed. RESULTS The high shear stress in the extracorporeal circulation rapidly decreased VWF:RCo and thereby the VWF:RCo/VWF:Ag ratio by 47% (p<0.01) to pathologically low values. Concomitantly, high molecular weight multimers (HMWM) decreased: up to 14-15 mers were visible on the gels at baseline, which were reduced by a maximum of 6-7 mers, corresponding to an average 68% lower densitometry signal of HMWM (p<0.001). This was accompanied by marked reduction of aggregation by various agonists (p<0.005). In contrast, the two patients with congenital thrombocytopenic purpura with virtually complete deficiency of ADAMTS-13 activity had only a minimal or no decrease in multimers (p<0.005 vs. healthy controls). Similarly, no or minimal depletion of large multimers occurred, when normal plasma circulated without platelets. CONCLUSION An in vitro model for LVAD associated aVWD demonstrated that ADAMTS-13 and platelets contribute to the depletion of HMWM of VWF.
Collapse
Affiliation(s)
- Petra Jilma-Stohlawetz
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Division of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Austria
| | - Heinrich Schima
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Austria
| | - Martin Stoiber
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Austria
| | - Paul Knöbl
- Department of Internal Medicine I, Division of Haematology and Haemostasis, Medical University of Vienna, Austria
| | - Barbara Steinlechner
- Division of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, Austria
| | - Alessia Felli
- Division of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, Austria
| | - Bernd Jilma
- Clinical Pharmacology, Medical University of Vienna, Austria.
| |
Collapse
|
28
|
Bonazza K, Rottensteiner H, Schrenk G, Frank J, Allmaier G, Turecek PL, Scheiflinger F, Friedbacher G. Shear-Dependent Interactions of von Willebrand Factor with Factor VIII and Protease ADAMTS 13 Demonstrated at a Single Molecule Level by Atomic Force Microscopy. Anal Chem 2015; 87:10299-305. [PMID: 26369694 DOI: 10.1021/acs.analchem.5b02078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Vital functions of mammals are only possible due to the behavior of blood to coagulate most efficiently in vessels with particularly high wall shear rates. This is caused by the functional changes of the von Willebrand Factor (VWF), which mediates coagulation of blood platelets (primary hemostasis) especially when it is stretched under shear stress. Our data show that shear stretching also affects other functions of VWF: Using a customized device to simulate shear conditions and to conserve the VWF molecules in their unstable, elongated conformation, we visualize at single molecule level by AFM that VWF is preferentially cleaved by the protease ADAMTS13 at higher shear rates. In contrast to this high shear-rate-selective behavior, VWF binds FVIII more effectively only below a critical shear rate of ∼30.000 s(-1), indicating that under harsh shear conditions FVIII is released from its carrier protein. This may be required to facilitate delivery of FVIII locally to promote secondary hemostasis.
Collapse
Affiliation(s)
- Klaus Bonazza
- Institute of Chemical Technologies and Analytics, Vienna University of Technology , Getreidemarkt 9/164, A-1060 Vienna, Austria
| | | | - Gerald Schrenk
- Baxalta Innovations, Industriestrasse 67, A-1221 Vienna, Austria
| | - Johannes Frank
- Central Machine Shop of the Faculty Technical Chemistry, Vienna University of Technology , Getreidemarkt 9/174, A-1060 Vienna, Austria
| | - Günter Allmaier
- Institute of Chemical Technologies and Analytics, Vienna University of Technology , Getreidemarkt 9/164, A-1060 Vienna, Austria
| | - Peter L Turecek
- Baxalta Innovations, Industriestrasse 67, A-1221 Vienna, Austria
| | | | - Gernot Friedbacher
- Institute of Chemical Technologies and Analytics, Vienna University of Technology , Getreidemarkt 9/164, A-1060 Vienna, Austria
| |
Collapse
|
29
|
Bischof DB, Ganter MT, Shore-Lesserson L, Hartnack S, Klaghofer R, Graves K, Genoni M, Hofer CK. Viscoelastic Blood Coagulation Measurement With Sonoclot Predicts Postoperative Bleeding in Cardiac Surgery After Heparin Reversal. J Cardiothorac Vasc Anesth 2015; 29:715-22. [DOI: 10.1053/j.jvca.2015.01.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Indexed: 01/22/2023]
|
30
|
Blackshear JL, Wysokinska EM, Safford RE, Thomas CS, Shapiro BP, Ung S, Stark ME, Parikh P, Johns GS, Chen D. Shear stress-associated acquired von Willebrand syndrome in patients with mitral regurgitation. J Thromb Haemost 2014; 12:1966-74. [PMID: 25251907 DOI: 10.1111/jth.12734] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 09/17/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mitral valve regurgitation is associated with an acquired hemostatic defect. OBJECTIVE We sought to assess the prevalence and severity of acquired von Willebrand syndrome in patients with native valve mitral regurgitation (MR). PATIENTS/METHODS Fifty-three patients were prospectively observed with bleeding questionnaires and laboratory tests when undergoing an echocardiographic assessment of MR. In patients referred for mitral valve surgery, testing was repeated postoperatively. RESULTS Echocardiography identified 13 patients with mild MR, 14 with moderate MR, and 26 with severe MR. Among patients with mild, moderate or severe MR, loss of the highest molecular weight von Willebrand factor (VWF) multimers occurred in 8%, 64%, and 85%, respectively, median platelet function analyzer collagen ADP closure times (PFA-CADPs) were 84 s (interquartile range [IQR] 73-96 s), 156 s (IQR 104-181 s), and 190 s (IQR 157-279 s), respectively, and the ratios of VWF latex activity to antigen were 0.92 (IQR 0.83-0.97), 0.85 (IQR 0.76-0.89), and 0.79 (IQR 0.75-0.82), respectively (all P < 0.001). Nine patients reported clinically significant bleeding, and seven had intestinal angiodysplasia and transfusion-dependent gastrointestinal bleeding (Heyde syndrome), with the median number of transfusions required being 20 (IQR 10-33; range 4-50). In patients who underwent mitral valve repair (n = 13) or replacement (n = 7), all measures of VWF function reported above improved significantly. CONCLUSION The high-shear environment of moderate to severe MR is sufficient to produce prevalent perturbations in VWF activity. Acquired von Willebrand syndrome may occur in this setting, and appears to be reversible with mitral valve surgery.
Collapse
Affiliation(s)
- J L Blackshear
- Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Incidence, Predictors, and Prognostic Impact of Late Bleeding Complications After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2014; 64:2605-2615. [DOI: 10.1016/j.jacc.2014.08.052] [Citation(s) in RCA: 162] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/01/2014] [Accepted: 08/31/2014] [Indexed: 11/17/2022]
|
32
|
Morshuis M, Özpeker C, Schulz U, Gummert J, Koster A. Herzunterstützungssysteminduzierte Störungen der Gerinnung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1050-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
33
|
Acquired von Willebrand syndrome in adult patients with congenital heart disease. Int J Cardiol 2014; 176:739-45. [DOI: 10.1016/j.ijcard.2014.07.104] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 06/14/2014] [Accepted: 07/26/2014] [Indexed: 11/22/2022]
|
34
|
Görlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, Rahe-Meyer N, Tanaka KA. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth 2014; 27:S20-34. [PMID: 23910533 DOI: 10.1053/j.jvca.2013.05.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bleeding is an important issue in cardiothoracic surgery, and about 20% of all blood products are transfused in this clinical setting worldwide. Transfusion practices, however, are highly variable among different hospitals and more than 25% of allogeneic blood transfusions have been considered inappropriate. Furthermore, both bleeding and allogeneic blood transfusion are associated with increased morbidity, mortality, and hospital costs. In the past decades, several attempts have been made to find a universal hemostatic agent to ensure hemostasis during and after cardiothoracic surgery. Most drugs studied in this context have either failed to reduce bleeding and transfusion requirements or were associated with severe adverse events, such as acute renal failure or thrombotic/thromboembolic events and, in some cases, increased mortality. Therefore, an individualized goal-directed hemostatic therapy ("theranostic" approach) seems to be more appropriate to stop bleeding in this complex clinical setting. The use of point-of-care (POC) transfusion and coagulation management algorithms guided by viscoelastic tests such as thromboelastometry/thromboelastography in combination with POC platelet function tests such as whole blood impedance aggregometry, and based on first-line therapy with fibrinogen and prothrombin complex concentrate have been associated with reduced allogeneic blood transfusion requirements, reduced incidence of thrombotic/thromboembolic and transfusion-related adverse events, and improved outcomes in cardiac surgery. This article reviews the current literature dealing with the management of hemorrhage in cardiothoracic surgery based on POC diagnostics and with specific coagulation factor concentrates and its impact on transfusion requirements and patients' outcomes.
Collapse
Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | | | | | | | | | | |
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW On the one hand, cardiac and aortic surgery is associated with a high rate of allogeneic blood transfusion. On the other hand, both bleeding and allogeneic blood transfusion is associated with increased morbidity, mortality, and hospital costs in cardiac and aortic surgery. This article reviews the current literature between 1995 and 2012 dealing with transfusion protocols in cardiovascular surgery. The 16 studies fitting these search criteria have evaluated the impact of the implementation of ROTEM/TEG based coagulation management algorithms on transfusion requirement and outcome in overall 8507 cardiovascular surgical patients. RECENT FINDINGS The use of point-of-care (POC) transfusion and coagulation management algorithms based on viscoelastic tests such as thromboelastometry (ROTEM) and thrombelastography (TEG) in combination with POC platelet function tests such as whole blood impedance aggregometry (Multiplate) have been shown to be associated with reduced allogeneic blood transfusion requirements, reduced incidence of thrombotic/thromboembolic and transfusion-related adverse events, and improved outcomes in cardiac surgery. SUMMARY Implementation of POC algorithms including a comprehensive bundle of POC diagnostics (thromboelastometry and whole blood impedance aggregometry) in combination with first-line therapy using immediately available specific coagulation factor concentrates (fibrinogen and prothrombin complex concentrate) and defining strict indications, calculated dosages, and clear sequences for each haemostatic intervention seems to be complex but most effective in reducing perioperative transfusion requirements and has been shown to be associated with a decreased incidence of thrombotic/thromboembolic events, transfusion-related adverse events, as well as with improved patients' outcomes including 6-month mortality.
Collapse
|
36
|
Blackshear JL, Wysokinska EM, Safford RE, Thomas CS, Stark ME, Shapiro BP, Ung S, Johns GS, Chen D. Indexes of von Willebrand factor as biomarkers of aortic stenosis severity (from the Biomarkers of Aortic Stenosis Severity [BASS] study). Am J Cardiol 2013; 111:374-81. [PMID: 23168287 DOI: 10.1016/j.amjcard.2012.10.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 10/04/2012] [Accepted: 10/04/2012] [Indexed: 01/28/2023]
Abstract
We correlated von Willebrand factor (VWF) activity indexes and brain natriuretic peptide (BNP) with measures of aortic stenosis (AS) severity, bleeding, symptoms, and freedom from death or aortic valve replacement. Patients with AS (n = 66 [16 mild, 20 moderate, and 30 severe]) and aortic valve replacement (n = 21) were assessed with VWF antigen, VWF latex agglutination immunoturbidic activity, platelet function analyzer collagen plus adenosine diphosphate (PFA-CADP), VWF multimer ratio, and BNP level after echocardiography. In patients with AS, the mean gradient correlated with BNP (Spearman r = 0.29, p = 0.02), VWF latex agglutination immunoturbidic activity/VWF antigen ratio (r = -0.41, p <0.001), PFA-CADP (r = 0.49, p <0.001), and VWF multimer ratio (r = -0.76, p <0.001). The area under the curve for detection of severe AS was 0.62 (95% confidence interval [CI] 0.48 to 0.77) by elevated BNP, 0.81 (95% CI 0.69 to 0.92) by PFA-CADP closure time, 0.69 (95% CI 0.55 to 0.82) by VWF latex agglutination immunoturbidic activity/VWF antigen ratio, and 0.86 (95% CI 0.76 to 0.95) by VWF multimer ratio. For the VWF multimer ratio, a threshold of 0.15 yielded a sensitivity and specificity for severe AS of 77% and positive predictive value of 74%. Bleeding (in 14%) was associated with a prolonged PFA-CADP time and reduced VWF latex agglutination immunoturbidic activity/VWF antigen ratio. Symptoms were associated with elevated BNP and low Duke Activity Status Index score. In 66 patients with AS, freedom from death (n = 4) or aortic valve replacement (n = 22) was associated with PFA-CADP (p = 0.003), VWF high-molecular-weight multimers (p = 0.009), and VWF latex agglutination immunoturbidic activity/VWF antigen ratio (p <0.001) but not BNP (p = 0.32). In severe AS versus aortic valve replacement, the PFA-CADP and VWF multimer ratio differed (p <0.001), but BNP and the VWF latex agglutination immunoturbidic activity/VWF antigen ratio did not. In conclusion, the VWF activity indexes were associated with AS severity and bleeding and were predictive of cardiovascular outcomes.
Collapse
|
37
|
Wiegand G, Hofbeck M, Zenker M, Budde U, Rauch R. Bleeding diathesis in Noonan syndrome: is acquired von Willebrand syndrome the clue? Thromb Res 2012; 130:e251-4. [PMID: 22985731 DOI: 10.1016/j.thromres.2012.08.314] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 08/10/2012] [Accepted: 08/28/2012] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Noonan syndrome (NS) is characterized by dysmorphic facies, short stature and congenital heart defects. Various haemostatic disorders have been described in NS patients, but not all were related to bleeding, which itself is present in up to 65%. Several subgroups of NS - especially those with PTPN11 mutation - are associated with pulmonary stenosis. As it is known that some heart defects are prone to a shear stress related destruction of the von Willebrand factor as an important haemostatic component, we aimed to find out, whether the pulmonary stenosis could be responsible for such a mechanism in NS patients. PATIENTS, METHODS AND RESULTS We investigated the haemostatic system in 15 children with genetically proven NS (14 with PTPN11, one with SOS1 mutation). Platelet count, basic coagulation parameters, fibrinogen and antithrombin were normal in all patients, none had a relevant reduction of coagulation factor activities. Five patients had pulmonary valve stenosis with systolic gradients>60 mmHg. In three of them a deficiency of the high molecular weight multimers and a pathologic collagen-binding capacity were detected, suggesting acquired von Willebrand syndrome. Nine of our patients indicated a relevant bleeding diathesis and complained of easy bruising, three reported spontaneous gum bleeding. IN CONCLUSION the destruction of the von Willebrand factor could explain the bleeding in some of the NS patients with pulmonary valve stenosis. Our finding is of clinical relevance since most of these patients require either interventional cardiac catheterization or open heart surgery which may be complicated by the haemorrhagic tendency.
Collapse
Affiliation(s)
- Gesa Wiegand
- Department of Pediatric Cardiology, University Children´s Hospital, Hoppe-Seyler-Str. 1, 72076 Tuebingen, Germany.
| | | | | | | | | |
Collapse
|
38
|
Severe upper gastrointestinal bleeding in Heartmate II induced by acquired von Willebrand deficiency: anticoagulation management. Ann Thorac Surg 2012; 94:e41-3. [PMID: 22579885 DOI: 10.1016/j.athoracsur.2012.01.087] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 12/20/2011] [Accepted: 01/20/2012] [Indexed: 11/20/2022]
Abstract
Patients treated with continuous flow assist devices may have increased bleeding tendencies due to an induced high molecular weight von Willebrand factor (VWF) multimer deficiency. We report a patient supported with a HeartMate II (Thoratec, Pleasanton, CA) who developed severe gastrointestinal bleeding refractory to conventional therapy and needing a total of 60 transfusions. After documenting the lack of large VWF multimers, suggestive of a defective platelet function, the patient was switched from aspirin to warfarin therapy (target international normalized ratio between 1.5 and 2.0). Three days after changing the anticoagulant regimen, the patient stopped bleeding and required no further transfusion.
Collapse
|
39
|
Johansson PI, Sølbeck S, Genet G, Stensballe J, Ostrowski SR. Coagulopathy and hemostatic monitoring in cardiac surgery: an update. SCAND CARDIOVASC J 2012; 46:194-202. [PMID: 22375889 DOI: 10.3109/14017431.2012.671487] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Cardiac surgery with cardiopulmonary bypass (CPB) causes severe derangements in the hemostatic system, which in turn puts the patient at risks of microvascular bleeding. Excessive transfusion and surgical re-exploration after cardiac surgery are potentially associated with a number of adverse outcomes including increased mortality. DESIGN This review describes coagulopathies occurring in cardiac surgery and the monitoring of these. Viscoelastic hemostatic assays (VHA) have routinely been used in cardiac surgery for more than 25 years and at least 16 studies (involving more than 3250 patients, including three randomized controlled trials) have compared VHA to routine coagulation tests (RCoT) with regards to their ability to predict bleeding and re-do surgery and also with regards to transfusion requirements secondary to hemostatic therapy based on VHA vs. RCoT. RESULTS All 16 studies demonstrated superiority with VHA as compared to RCoT both in predicting bleeding and need for re-do surgery and in reducing the total amount of blood transfusions by employing goal-directed administration of blood products based on VHA as compared RCoT based therapy or at the clinicians discretion. CONCLUSIONS The different types of coagulopathies observed in patients undergoing cardiac surgery requires adequate and timely hemostatic therapy and real-time monitoring with WHA such as TEG/ROTEM and whole blood platelet aggregometry.
Collapse
Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Denmark.
| | | | | | | | | |
Collapse
|
40
|
Bolliger D, Dell-Kuster S, Seeberger MD, Tanaka KA, Gregor M, Zenklusen U, Tsakiris DA, Filipovic M. Impact of loss of high-molecular-weight von Willebrand factor multimers on blood loss after aortic valve replacement. Br J Anaesth 2012; 108:754-62. [PMID: 22311365 DOI: 10.1093/bja/aer512] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Severe aortic stenosis is associated with loss of the largest von Willebrand factor (vWF) multimers, which could affect primary haemostasis. We hypothesized that the altered multimer structure with the loss of the largest multimers increases postoperative bleeding in patients undergoing aortic valve replacement. METHODS We prospectively included 60 subjects with severe aortic stenosis. Before and after aortic valve replacement, vWF antigen, activity, and multimer structure were determined and platelet function was measured by impedance aggregometry. Blood loss from mediastinal drainage and the use of blood and haemostatic products were evaluated perioperatively. RESULTS Before operation, the altered multimer structure was present in 48 subjects (80%). Baseline characteristics and laboratory data were similar in all subjects. The median blood loss after 6 h was 250 (105-400) and 145 (85-240) ml in the groups with the altered and normal multimer structures, respectively (P=0.182). After 24 h, the cumulative loss was 495 (270-650) and 375 (310-600) ml in the groups with the altered and normal multimer structures, respectively (P=0.713). Multivariable analysis revealed no significant influence of multimer structure and platelet function on bleeding volumes after 6 and 24 h. After 24 h, there was no obvious difference in vWF antigen, activity, and multimer structure in subjects with and without the altered multimer structure before operation or in subjects with and without perioperative plasma transfusion. CONCLUSIONS The altered vWF multimer structure before operation was not associated with increased bleeding after aortic valve replacement. Our findings might be explained by perioperative release of vWF and rapid recovery of the largest vWF multimers.
Collapse
Affiliation(s)
- D Bolliger
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
| | | | | | | | | | | | | | | |
Collapse
|