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Bolliger D, Ranucci M. Improved outcome with individualised antifibrinolytic therapy: what is the evidence? Br J Anaesth 2024; 132:1187-1189. [PMID: 38729743 DOI: 10.1016/j.bja.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 05/12/2024] Open
Abstract
Viscoelastic haemostatic testing (VHT) has been used to determine hyperfibrinolysis and hypofibrinolysis. When modified by addition of tissue plasminogen activator (tPA), VHT has been suggested to assess responses to antifibrinolytic therapy and to estimate the concentration of tranexamic acid in patients undergoing cardiac surgery. Despite some evidence that tPA-modified VHT might allow individualisation of antifibrinolytic therapy, further studies are warranted to prove its clinical benefit for postsurgical bleeding, transfusion of blood products, and thromboembolic events.
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Affiliation(s)
- Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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2
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Wang Q, Qin Y, Ma J, Zhou K, Xia G, Li Y, Xie L, Afful RG, Lan Q, Huo X, Zou J, Yang H. An early warning indicator of mortality risk in patients with COVID-19: the neutrophil extracellular traps/neutrophilic segmented granulocyte ratio. Front Immunol 2024; 15:1287132. [PMID: 38348024 PMCID: PMC10859410 DOI: 10.3389/fimmu.2024.1287132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/15/2024] [Indexed: 02/15/2024] Open
Abstract
Background Neutrophil extracellular traps (NETs) play a key role in thrombus formation in patients with coronavirus disease 2019 (COVID-19). However, the existing detection and observation methods for NETs are limited in their ability to provide quantitative, convenient, and accurate descriptions of in situ NETs. Therefore, establishing a quantitative description of the relationship between NETs and thrombosis remains a challenge. Objective We employed morphological observations of blood cells and statistical analyses to investigate the correlation between the NETs/neutrophilic segmented granulocyte ratio and mortality risk in patients with COVID-19. Methods Peripheral blood samples were collected from 117 hospitalized patients with COVID-19 between November 2022 and February 2023, and various blood cell parameters were measured. Two types of smudge cells were observed in the blood and counted: lymphatic and neutral smudge cells. Statistical data analysis was used to establish COVID-19 mortality risk assessment indicators. Results Morphological observations of neutrophilic smudge cells revealed swelling, eruption, and NETs formation in the neutrophil nuclei. Subsequently, the NETs/neutrophilic segmented granulocyte ratio (NNSR) was calculated. A high concentration of NETs poses a fatal risk for thrombus formation in patients. Statistical analysis indicated that a high NNSR was more suitable for evaluating the risk of death in patients with COVID-19 compared to elevated fibrinogen (FIB) and D-dimer (DD) levels. Conclusion Observing blood cell morphology is an effective method for the detection of NETs, NNSR are important markers for revealing the mortality risk of patients with COVID-19.
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Affiliation(s)
- Qiong Wang
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Yu Qin
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Jingyun Ma
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Kehao Zhou
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Guiping Xia
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Ya Li
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Li Xie
- School of Internet of Things Engineering, Jiangnan University, Wuxi, China
| | - Richmond Godwin Afful
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Qian Lan
- School of Internet of Things Engineering, Jiangnan University, Wuxi, China
| | - Xingyu Huo
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
| | - Jian Zou
- The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, China
| | - Hailin Yang
- Key Laboratory of Industrial Biotechnology, Ministry of Education, School of Biotechnology, Jiangnan University, Wuxi, China
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Whyte CS. All tangled up: interactions of the fibrinolytic and innate immune systems. Front Med (Lausanne) 2023; 10:1212201. [PMID: 37332750 PMCID: PMC10272372 DOI: 10.3389/fmed.2023.1212201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
The hemostatic and innate immune system are intertwined processes. Inflammation within the vasculature promotes thrombus development, whilst fibrin forms part of the innate immune response to trap invading pathogens. The awareness of these interlinked process has resulted in the coining of the terms "thromboinflammation" and "immunothrombosis." Once a thrombus is formed it is up to the fibrinolytic system to resolve these clots and remove them from the vasculature. Immune cells contain an arsenal of fibrinolytic regulators and plasmin, the central fibrinolytic enzyme. The fibrinolytic proteins in turn have diverse roles in immunoregulation. Here, the intricate relationship between the fibrinolytic and innate immune system will be discussed.
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Zeng Z, Nallan Chakravarthula T, Christodoulides A, Hall A, Alves NJ. Effect of Chandler loop shear and tubing size on thrombus architecture. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2023; 34:24. [PMID: 37173603 PMCID: PMC10182104 DOI: 10.1007/s10856-023-06721-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/17/2023] [Indexed: 05/15/2023]
Abstract
Thrombosis can lead to a wide variety of life-threatening circumstances. As current thrombolytic drug screening models often poorly predict drug profiles, leading to failure of thrombolytic therapy or clinical translation, more representative clot substrates are necessary for drug evaluation. Utilizing a Chandler loop device to form clot analogs at high shear has gained popularity in stroke societies. However, shear-dependent clot microstructure has not been fully addressed and low shear conditions are often overlooked. We herein characterized the impact of wall shear rate (126 to 951 s-1) on clot properties in the Chandler loop. Different revolutions (20-60) per minute and tubing sizes (3.2 to 7.9 mm) were employed to create different sized clots to mimic various thrombosis applications. Increased shear resulted in decreased RBC counts (76.9 ± 4.3% to 17.6 ± 0.9%) and increased fibrin (10 to 60%) based on clot histology. Increased fibrin sheet morphology and platelet aggregates were observed at higher shear under scanning electron microscope. These results show the significant impact of shear and tubing size on resulting clot properties and demonstrate the capability of forming a variety of reproducible in-vivo-like clot analogs in the Chandler loop device controlling for simple parameters to tune clot characteristics.
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Affiliation(s)
- Ziqian Zeng
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA
| | - Tanmaye Nallan Chakravarthula
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA
| | - Alexei Christodoulides
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abigail Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nathan J Alves
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA.
- Department of Biochemistry & Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA.
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Zeng Z, Christodoulides A, Alves NJ. Real-time tracking of fibrinolysis under constant wall shear and various pulsatile flows in an in-vitro thrombolysis model. Bioeng Transl Med 2023; 8:e10511. [PMID: 37206217 PMCID: PMC10189439 DOI: 10.1002/btm2.10511] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/06/2023] [Accepted: 03/08/2023] [Indexed: 05/21/2023] Open
Abstract
A great need exists for the development of a more representative in-vitro model to efficiently screen novel thrombolytic therapies. We herein report the design, validation, and characterization of a highly reproducible, physiological scale, flowing clot lysis platform with real-time fibrinolysis monitoring to screen thrombolytic drugs utilizing a fluorescein isothiocyanate (FITC)-labeled clot analog. Using this Real-Time Fluorometric Flowing Fibrinolysis assay (RT-FluFF assay), a tPa-dependent degree of thrombolysis was observed both via clot mass loss as well as fluorometrically monitored release of FITC-labeled fibrin degradation products. Percent clot mass loss ranged from 33.6% to 85.9% with fluorescence release rates of 0.53 to 1.17 RFU/min in 40 and 1000 ng/mL tPa conditions, respectively. The platform is easily adapted to produce pulsatile flows. Hemodynamics of human main pulmonary artery were mimicked through matching dimensionless flow parameters calculated using clinical data. Increasing pressure amplitude range (4-40 mmHg) results in a 20% increase of fibrinolysis at 1000 ng/mL tPA. Increasing shear flow rate (205-913 s-1) significantly increases fibrinolysis and mechanical digestion. These findings suggest pulsatile level affects thrombolytic drug activities and the proposed in-vitro clot model offers a versatile testing platform for thrombolytic drug screening.
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Affiliation(s)
- Ziqian Zeng
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Weldon School of Biomedical EngineeringPurdue UniversityWest LafayetteIndianaUSA
| | - Alexei Christodoulides
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Nathan J. Alves
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Weldon School of Biomedical EngineeringPurdue UniversityWest LafayetteIndianaUSA
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Narwal A, Whyte CS, Mutch NJ. Location, location, location: Fibrin, cells, and fibrinolytic factors in thrombi. Front Cardiovasc Med 2023; 9:1070502. [PMID: 36741833 PMCID: PMC9889369 DOI: 10.3389/fcvm.2022.1070502] [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: 10/14/2022] [Accepted: 12/16/2022] [Indexed: 01/20/2023] Open
Abstract
Thrombi are heterogenous in nature with composition and structure being dictated by the site of formation, initiating stimuli, shear stress, and cellular influences. Arterial thrombi are historically associated with high platelet content and more tightly packed fibrin, reflecting the shear stress in these vessels. In contrast, venous thrombi are generally erythrocyte and fibrin-rich with reduced platelet contribution. However, these conventional views on the composition of thrombi in divergent vascular beds have shifted in recent years, largely due to recent advances in thromboectomy and high-resolution imaging. Interestingly, the distribution of fibrinolytic proteins within thrombi is directly influenced by the cellular composition and vascular bed. This in turn influences the susceptibility of thrombi to proteolytic degradation. Our current knowledge of thrombus composition and its impact on resistance to thrombolytic therapy and success of thrombectomy is advancing, but nonetheless in its infancy. We require a deeper understanding of thrombus architecture and the downstream influence on fibrinolytic susceptibility. Ultimately, this will aid in a stratified and targeted approach to tailored antithrombotic strategies in patients with various thromboembolic diseases.
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Whyte CS, Mutch NJ. “Going with the flow” in modeling fibrinolysis. Front Cardiovasc Med 2022; 9:1054541. [DOI: 10.3389/fcvm.2022.1054541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022] Open
Abstract
The formation of thrombi is shaped by intravascular shear stress, influencing both fibrin architecture and the cellular composition which has downstream implications in terms of stability against mechanical and fibrinolytic forces. There have been many advancements in the development of models that incorporate flow rates akin to those found in vivo. Both thrombus formation and breakdown are simultaneous processes, the balance of which dictates the size, persistence and resolution of thrombi. Therefore, there is a requirement to have models which mimic the physiological shear experienced within the vasculature which in turn influences the fibrinolytic degradation of the thrombus. Here, we discuss various assays for fibrinolysis and importantly the development of novel models that incorporate physiological shear rates. These models are essential tools to untangle the molecular and cellular processes which govern fibrinolysis and can recreate the conditions within normal and diseased vessels to determine how these processes become perturbed in a pathophysiological setting. They also have utility to assess novel drug targets and antithrombotic drugs that influence thrombus stability.
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Kanji R, Gue YX, Farag MF, Spencer NH, Mutch NJ, Gorog DA. Determinants of Endogenous Fibrinolysis in Whole Blood Under High Shear in Patients With Myocardial Infarction. JACC Basic Transl Sci 2022; 7:1069-1082. [PMID: 36687271 PMCID: PMC9849272 DOI: 10.1016/j.jacbts.2022.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 01/25/2023]
Abstract
Hypofibrinolysis is a recently-recognized risk factor for recurrent cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI), but the mechanistic determinants of this are not well understood. In patients with STEMI, we show that the effectiveness of endogenous fibrinolysis in whole blood is determined in part by fibrinogen level, high sensitivity C-reactive protein, and shear-induced platelet reactivity, the latter directly related to the speed of thrombin generation. Our findings strengthen the evidence for the role of cellular components and bidirectional crosstalk between coagulatory and inflammatory pathways as determinants of hypofibrinolysis.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom
| | - Ying X. Gue
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Mohamed F. Farag
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Neil H. Spencer
- Statistical Services and Consultancy Unit, Hertfordshire Business School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Nicola J. Mutch
- Aberdeen Cardiovascular and Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Diana A. Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom,Address for correspondence: Prof Diana A. Gorog, Faculty of Medicine, National Heart and Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, United Kingdom.
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