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Škiljić S, Nešković N, Kristek G, Milić M, Vinković H, Kedačić K, Kvolik S. POINT-OF-CARE DIAGNOSTIC APPROACH IN A CRITICALLY ILL PATIENT WITH SEVERE BLEEDING FROM URINARY TRACT. Acta Clin Croat 2023; 62:138-142. [PMID: 38966024 PMCID: PMC11221227 DOI: 10.20471/acc.2023.62.s2.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024] Open
Abstract
Coagulation disorders in critically ill patients presenting with bleeding can be multicausal. The drugs applied can interfere and impair the coagulation cascade. Point-of-care (POC) coagulation assays may resolve difficult therapeutic situations in critical illness. We report on a 73-year-old critically ill male patient with massive hematuria after bladder lithotripsy. The patient was on low molecular weight heparin therapy due to recent pulmonary embolism. He was subjected to repeated surgical hemostasis which was ineffective despite massive transfusion protocol and normal standard coagulation profile. Additional POC coagulation assays were obtained and were indicative of platelet dysfunction. We revised his medical therapy and suspected the possible drug influence on platelet aggregation. After discontinuation of target drug, platelet aggregation increased whereas hematuria stopped. Coagulation disorders in intensive care unit patients are often multifactorial. Standard laboratory tests are unreliable in complex refractory bleeding and may result in inappropriate therapeutic decisions. Stepwise approach with assessment of clinical parameters, present therapy, and a combination of POC coagulation tests is the key to optimal therapeutic management.
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Affiliation(s)
- Sonja Škiljić
- Department of Anesthesiology and Intensive care unit, Osijek University Hospital Center, Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Nenad Nešković
- Department of Anesthesiology and Intensive care unit, Osijek University Hospital Center, Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Gordana Kristek
- Department of Anesthesiology and Intensive care unit, Osijek University Hospital Center, Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Marija Milić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Clinical Laboratory Diagnostics, Osijek University Hospital Center, Osijek, Croatia
| | - Hrvoje Vinković
- Department of Anesthesiology and Intensive care unit, Osijek University Hospital Center, Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Karlo Kedačić
- Department of Anesthesiology and Intensive care unit, Osijek University Hospital Center, Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Slavica Kvolik
- Department of Anesthesiology and Intensive care unit, Osijek University Hospital Center, Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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Roka-Moiia Y, Ammann KR, Miller-Gutierrez S, Sheriff J, Bluestein D, Italiano JE, Flaumenhaft RC, Slepian MJ. Shear-Mediated Platelet Microparticles Demonstrate Phenotypic Heterogeneity as to Morphology, Receptor Distribution, and Hemostatic Function. Int J Mol Sci 2023; 24:7386. [PMID: 37108551 PMCID: PMC10138836 DOI: 10.3390/ijms24087386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Implantable Cardiovascular Therapeutic Devices (CTD), while lifesaving, impart supraphysiologic shear stress to platelets, resulting in thrombotic and bleeding coagulopathy. We previously demonstrated that shear-mediated platelet dysfunction is associated with downregulation of platelet GPIb-IX-V and αIIbβ3 receptors via generation of Platelet-Derived MicroParticles (PDMPs). Here, we test the hypothesis that sheared PDMPs manifest phenotypical heterogeneity of morphology and receptor surface expression and modulate platelet hemostatic function. Human gel-filtered platelets were exposed to continuous shear stress. Alterations of platelet morphology were visualized using transmission electron microscopy. Surface expression of platelet receptors and PDMP generation were quantified by flow cytometry. Thrombin generation was quantified spectrophotometrically, and platelet aggregation was measured by optical aggregometry. Shear stress promotes notable alterations in platelet morphology and ejection of distinctive types of PDMPs. Shear-mediated microvesiculation is associated with the remodeling of platelet receptors, with PDMPs expressing significantly higher levels of adhesion receptors (αIIbβ3, GPIX, PECAM-1, P-selectin, and PSGL-1) and agonist receptors (P2Y12 and PAR1). Sheared PDMPs promote thrombin generation and inhibit platelet aggregation induced by collagen and ADP. Sheared PDMPs demonstrate phenotypic heterogeneity as to morphology and defined patterns of surface receptors and impose a bidirectional effect on platelet hemostatic function. PDMP heterogeneity suggests that a range of mechanisms are operative in the microvesiculation process, contributing to CTD coagulopathy and posing opportunities for therapeutic manipulation.
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Affiliation(s)
- Yana Roka-Moiia
- Sarver Heart Center, Departments of Medicine and Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Building 201E, Room 6139, Tucson, AZ 85724, USA; (Y.R.-M.)
| | - Kaitlyn R. Ammann
- Sarver Heart Center, Departments of Medicine and Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Building 201E, Room 6139, Tucson, AZ 85724, USA; (Y.R.-M.)
| | - Samuel Miller-Gutierrez
- Sarver Heart Center, Departments of Medicine and Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Building 201E, Room 6139, Tucson, AZ 85724, USA; (Y.R.-M.)
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Joseph E. Italiano
- Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Robert C. Flaumenhaft
- Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Marvin J. Slepian
- Sarver Heart Center, Departments of Medicine and Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Building 201E, Room 6139, Tucson, AZ 85724, USA; (Y.R.-M.)
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Roka-Moiia Y, Ammann K, Miller-Gutierrez S, Sheriff J, Bluestein D, Italiano JE, Flaumenhaft RC, Slepian MJ. Shear-Mediated Platelet Microparticles Demonstrate Phenotypic Heterogeneity as to Morphology, Receptor Distribution, and Hemostatic Function. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.08.527675. [PMID: 36798322 PMCID: PMC9934663 DOI: 10.1101/2023.02.08.527675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Objective Implantable cardiovascular therapeutic devices (CTD) including stents, percutaneous heart valves and ventricular assist devices, while lifesaving, impart supraphysiologic shear stress to platelets resulting in thrombotic and bleeding device-related coagulopathy. We previously demonstrated that shear-mediated platelet dysfunction is associated with downregulation of platelet GPIb-IX-V and αIIbβ3 receptors via generation of platelet-derived microparticles (PDMPs). Here, we test the hypothesis that shear-generated PDMPs manifest phenotypical heterogeneity of their morphology and surface expression of platelet receptors, and modulate platelet hemostatic function. Approach and Results Human gel-filtered platelets were exposed to continuous shear stress and sonication. Alterations of platelet morphology were visualized using transmission electron microscopy. Surface expression of platelet receptors and PDMP generation were quantified by flow cytometry. Thrombin generation was quantified spectrophotometrically, and platelet aggregation in plasma was measured by optical aggregometry. We demonstrate that platelet exposure to shear stress promotes notable alterations in platelet morphology and ejection of several distinctive types of PDMPs. Shear-mediated microvesiculation is associated with the differential remodeling of platelet receptors with PDMPs expressing significantly higher levels of both adhesion (α IIb β 3 , GPIX, PECAM-1, P-selectin, and PSGL-1) and agonist-evoked receptors (P 2 Y 12 & PAR1). Shear-mediated PDMPs have a bidirectional effect on platelet hemostatic function, promoting thrombin generation and inhibiting platelet aggregation induced by collagen and ADP. Conclusions Shear-generated PDMPs demonstrate phenotypic heterogeneity as to morphologic features and defined patterns of surface receptor alteration, and impose a bidirectional effect on platelet hemostatic function. PDMP heterogeneity suggests that a range of mechanisms are operative in the microvesiculation process, contributing to CTD coagulopathy and posing opportunities for therapeutic manipulation.
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Schlagenhauf A, Haidl H, Trummer G, Berchtold-Herz M, Pooth JS, Strini T, Geisen U, Beyersdorf F, Zieger B. The endogenous thrombin potential in patients with left ventricular assist device or heart transplant. Front Med (Lausanne) 2023; 10:1155496. [PMID: 37122335 PMCID: PMC10130672 DOI: 10.3389/fmed.2023.1155496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Background The Heartmate 3 (HM 3) is a left ventricular assist device featuring less shear stress, milder acquired von Willebrand syndrome, and fewer bleeding incidences than its predecessor the Heartmate II (HM II). The novel surface coating of the HM 3 suggests less contact activation of plasmatic coagulation. We hypothesized that patients with HM 3 exhibit fewer aberrations in their thrombin potential than patients with HM II. We compared these results with the thrombin potential of patients with heart transplantation (HTX). Methods Thrombin generation in plasma samples of patients with HM II (n = 16), HM 3 (n = 20), and HTX (n = 13) was analyzed 3 days after implantation/transplantation and after long-term support (3-24 months) with HM II (n = 16) or HM 3 (n = 12) using calibrated automated thrombography. Heparin in postoperative samples was antagonized with polybrene. Results Three days postoperatively HM II patients exhibited a lower endogenous thrombin potential (ETP) than HM 3 and HTX patients (HM II: 947 ± 291 nM*min; HM 3: 1231 ± 176 nM*min; HTX: 1376 ± 162 nM*min, p < 0.001) and a lower velocity index of thrombin generation (HM II: 18.74 ± 10.90 nM/min; HM 3: 32.41 ± 9.51 nM/min; HTX: 37.65 ± 9.41 nM/min, p < 0.01). Subtle differences in the thrombin generation profiles remained in HM II and HM 3 patients under long-term support (Velocity Index: HM II: 38.70 ± 28.46 nM/min; HM 3: 73.32 ± 32.83 nM/min, p < 0.05). Prothrombin fragments 1 + 2 were higher in HM II than in HM 3 patients (HM II: 377.7 ± 208.4 pM; HM 3: 202.1 ± 87.7 pM, p < 0.05) and correlated inversely with the ETP (r = -0.584, p < 0.05). Conclusion We observed a more aberrant thrombin generation in HM II than in HM 3 despite comparable anticoagulation and routine parameters. A trend toward lower values was still observable in HM 3 compared to HTX patients. Calibrated automated thrombography may be a good tool to monitor the coagulation state of these patients and guide anticoagulation in the future.
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Affiliation(s)
- Axel Schlagenhauf
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Harald Haidl
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Emergency Medicine, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg im Breisgau, Germany
| | - Tanja Strini
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Ulrich Geisen
- Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- *Correspondence: Barbara Zieger,
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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