Thrombocytopenia as a Preoperative Risk Assessment Tool in Patients With Rheumatic Heart Disease Undergoing Valve Replacement Surgery

Correlation between thrombocytopenia and adverse outcomes in patients with atrial fibrillation: a systematic review and meta-analysis

Background

Thrombocytopenia is often associated with adverse outcomes in patients with atrial fibrillation. Therefore, we conducted a meta-analysis to comprehensively assess the impact of thrombocytopenia on ischemic stroke/systemic embolism, major bleeding and all-cause mortality in patients with atrial fibrillation.

Methods

Two electronic databases, PubMed and Web of Science, were systematically searched from their inception to December 1, 2023, including the studies on the correlation between atrial fibrillation patients with thrombocytopenia and adverse outcomes. Relevant data was extracted, literature quality was evaluated, meta-analysis was performed by using REVMAN 5.4 software, and the results were reported with odds ratio (OR) of 95% confidence interval (CI).

Results

A total of 12 studies included 73,824 patients with atrial fibrillation (average age: 72.67, males: 42,275, 57.3%), among them, there were 7,673 patients combined with thrombocytopenia. The average follow-up time of these studies was 87 days to 55 months. Compared to no thrombocytopenia, atrial fibrillation patients combined with thrombocytopenia have a significant risk reduction of ischemic stroke/systemic embolism [OR: 0.79, 95% CI: (0.69, 0.91); P < 0.01]. Nevertheless, the risk of both major bleeding [OR: 1.51, 95% CI: (1.20, 1.79), P < 0.01] and all-cause mortality [OR: 1.40, 95% CI: (1.23, 1.61); P < 0.01] is significantly higher in thrombocytopenia group.

Conclusions

Thrombocytopenia has an important impact on the prognosis of patients with atrial fibrillation. Thrombocytopenia is significantly associated with a lower risk of ischemic stroke/systemic embolism but a higher risk of major bleeding and all-cause mortality. Attention to thrombocytopenia and optimization of treatment may be the effective way to improve the prognosis of atrial fibrillation with thrombocytopenia.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO Registration Number: (CRD42023459916).

Platelet count has a U-shaped association with mortality in hemodialysis patients

Our previous manuscript showed that thrombocytopenia predicts all-cause mortality in Chinese hemodialysis (HD) patients. Based on the role of platelets in coagulation, clot formation, and systemic inflammation, we speculate that high platelets increase risk of thrombo-embolic events, hence the mortality. However, research evidence is currently lacking. Therefore, we utilized data from a very large international cohort study to explore the association of platelet counts with mortality and cardiovascular (CV) death in hemodialysis (HD) patients. International data from 396 facilities enrolled in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 5 (2012-2015) were analyzed. Participants were divided into 3 groups according to their platelet counts (low: <100, normal: 100-300, high: >300*109). Associations between platelet counts and all-cause and CV mortality were analyzed using Cox regression, adjusted for confounders. There were 13,631 patients with median age of 65 years old. Males accounted for 61.2%. Mean platelet count was 205*109/L overall and ranged from 173 *109/L in China to 227 *109/L in Sweden. Overall, 2,348 (17.2%) patients died and 1017 (7.5%) died from CV disease. Both low (HR:1.48, 95% CI 1.21-1.80, p < 0.001) and high (HR:1.17, 95% CI 1.00- 1.35, p = 0.044) platelet counts were associated with higher all-cause mortality after adjustment for covariates; results for CV death were consistent. Platelet count has a U-shaped association with all-cause and CV mortality in HD patients, and thus may be used as an outcome predictor that is readily available among HD patients.

Impact of Thrombocytopenia in Patients With Atrial Fibrillation Undergoing Left Atrial Appendage Occlusion: A Propensity-Matched Comparison of 190 Consecutive Watchman Implantations

Objectives: The purpose of this study was to provide data on the long-term efficacy and safety of left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) and chronic thrombocytopenia (cTCP).

Methods: Between January 2016 and December 2018, a total of 32 AF patients with thrombocytopenia (platelet count <100^*10^∧9/L) undergoing LAAO at our center were identified and their outcomes were compared with a propensity-matched cohort (match ratio 1:5) of patients without cTCP who had also been indicated for LAAO.

Results: Between the cTCP patients and the control group, no difference was found on the incidence of stroke (0 vs. 3.13%, p = 0.592), systematic thromboembolisation (0 vs. 0.63%, p > 0.9) and device-related thrombus (DRT) (3.13 vs. 2.50%, p > 0.9). Major (12.50 vs. 3.75%, p = 0.065) and minor bleeding (15.63 vs. 1.25%, p = 0.002) was more frequent in cTCP patients but no statistical difference was reached in major bleeding. Moreover, thrombocytopenia was also identified as an independent predictor of any bleeding events (OR: 8.150, 95% CI: 2.579–25.757, p < 0.001), while an inverse relationship between higher absolute platelet count and stroke events was revealed (OR: 1.015; 95% CI: 1.002~1.029, p = 0.022). However, in both groups we saw a significant reduction in observed annualized rates of non-procedural complications compared with the predicted values. In the cTCP and control groups, clinical thromboembolism was reduced by 100 and 74.32%, and major bleeding by 42.47 and 71.67%, respectively.

Conclusion: Our preliminary results indicate that LAAO using the Watchman device could be a safe and effective means of preventing stroke in AF patients with or without thrombocytopenia, but bleeding complications should be monitored intensively in cTCP patients.

Risk Factors for Prognosis after the Maze IV Procedure in Patients with Atrial Fibrillation Undergoing Valve Surgery

The present study evaluated risk factors related to persistent atrial fibrillation (AF) at discharge (AF-d) and recurrentatrial fibrillation (rAF) and all-cause death after the maze IV procedure. Two hundred nineteen patients (63 female,aged 52.5 ± 8.8 years) with valve disease and persistent AF undergoing valve surgery and the maze IV procedure in our center between 2015 and 2016 were included. Baseline demographic and clinical data were obtained by review of medical records. The median follow-up period was 27 months (interquartile range 21–34 months) in our patient cohort.The primary end point was all-cause death. The secondary end point was AF-d or rAF. rAF is defined as AF recurrenceat 3 months or later after the procedure. Twenty-eight patients (12.8%) died during follow-up. Multiple logistic regression analysis showed that thrombocytopenia, elevated serum total bilirubin level, a larger right atrium, AF-d, and rAF were independent determinants for all-cause death after the maze IV procedure after adjustment for age, sex, and clinical covariates, including New York Heart Association class III/IV disease, hypertension, and aortic regurgitation, while valvular disease duration and left atrial diameter greater than 80.5 mm were independent determinants for AF-d, and thrombocytopenia, elevated serum total bilirubin level, higher mean pulmonary artery pressure, and AF-d were independent predictors for rAF. In conclusion, thrombocytopenia, elevated serum total bilirubin level, an enlarged right atrium, AF-d, and rAF are independent predictors of all-cause death in patients undergoing the maze IV procedure.