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Frederiks P, Bianchi P, Hunnybun D, Behar J, Garfield B, Ledot S. Single-center experience of temporary-permanent pacemaker use in COVID-19 patients supported with veno-venous ECMO: A case series. Perfusion 2024; 39:382-390. [PMID: 36476240 PMCID: PMC9742740 DOI: 10.1177/02676591221144905] [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] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In the first year of the COVID-19 pandemic, nine out of 129 patients (7%) developed life-threatening bradycardia episodes ultimately requiring a TPPM, whilst being supported with VV-ECMO for severe COVID-19 ARDS in our tertiary cardio-pulmonary failure center. ANALYSIS All subjects had asystole due to sinus node dysfunction and experienced at least one episode involving cardiopulmonary resuscitation. Most bradycardic events were seen in the context of vagal hypersensitivity. Mean time from general ICU admission to TPPM insertion was 20.6 ± 8.9 days. One patient developed a large chest wall hematoma weeks after TPPM implantation, no other TPPM-related issues were observed. No patient required a long-term pacing system. Six-months survival rate was high (89%). CONCLUSION These findings suggested that transient life-threatening sinus node disease is not uncommon in ECMO-dependent COVID-19 ARDS patients. TPPM with an active fixation lead is sometimes needed to facilitate ongoing ICU care, however, long-term permanent pacing was not required.
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Affiliation(s)
- Pascal Frederiks
- Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Paolo Bianchi
- Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Daniel Hunnybun
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Jonathan Behar
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ben Garfield
- Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stéphane Ledot
- Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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2
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Jonmarker S, Alarcón F, Litorell J, Granholm A, Alm EJ, Chew M, Russell L, Weihe S, Madsen EK, Meier N, Leistner JW, Mårtensson J, Hollenberg J, Perner A, Kjær MBN, Munch MW, Dahlberg M, Cronhjort M, Wahlin RR. Effects of 12 mg vs. 6 mg dexamethasone on thromboembolism and bleeding in patients with critical COVID-19 - a post hoc analysis of the randomized, blinded COVID STEROID 2 trial. Ann Intensive Care 2023; 13:12. [PMID: 36862239 PMCID: PMC9979892 DOI: 10.1186/s13613-023-01115-y] [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: 11/15/2022] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Thromboembolism is more common in patients with critical COVID-19 than in other critically ill patients, and inflammation has been proposed as a possible mechanism. The aim of this study was to investigate if 12 mg vs. 6 mg dexamethasone daily reduced the composite outcome of death or thromboembolism in patients with critical COVID-19. METHODS Using additional data on thromboembolism and bleeding we did a post hoc analysis of Swedish and Danish intensive care unit patients enrolled in the blinded randomized COVID STEROID 2 trial comparing 12 mg vs. 6 mg dexamethasone daily for up to 10 days. The primary outcome was a composite outcome of death or thromboembolism during intensive care. Secondary outcomes were thromboembolism, major bleeding, and any bleeding during intensive care. RESULTS We included 357 patients. Whilst in intensive care, 53 patients (29%) in the 12 mg group and 53 patients (30%) in the 6 mg group met the primary outcome with an unadjusted absolute risk difference of - 0.5% (95% CI - 10 to 9.5%, p = 1.00) and an adjusted OR of 0.93 (CI 95% 0.58 to 1.49, p = 0.77). We found no firm evidence of differences in any of the secondary outcomes. CONCLUSIONS Among patients with critical COVID-19, 12 mg vs. 6 mg dexamethasone daily did not result in a statistically significant difference in the composite outcome of death or thromboembolism. However, uncertainty remains due to the limited number of patients.
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Affiliation(s)
- Sandra Jonmarker
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden. .,Department of Anaesthesia and Intensive Care, Södersjukhuset, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden.
| | - Felix Alarcón
- grid.416648.90000 0000 8986 2221Department of Anaesthesia and Intensive Care, Södersjukhuset, Sjukhusbacken 10, SE-118 83 Stockholm, Sweden
| | - Jacob Litorell
- grid.416648.90000 0000 8986 2221Department of Anaesthesia and Intensive Care, Södersjukhuset, Sjukhusbacken 10, SE-118 83 Stockholm, Sweden
| | - Anders Granholm
- grid.475435.4Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark ,grid.512292.fCollaborations for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Eva Joelsson Alm
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden ,grid.416648.90000 0000 8986 2221Department of Anaesthesia and Intensive Care, Södersjukhuset, Sjukhusbacken 10, SE-118 83 Stockholm, Sweden
| | - Michelle Chew
- grid.5640.70000 0001 2162 9922Department of Anaesthesia and Intensive Care Medicine, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lene Russell
- grid.475435.4Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark ,grid.411646.00000 0004 0646 7402Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Sarah Weihe
- grid.512923.e0000 0004 7402 8188Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Emilie Kabel Madsen
- grid.154185.c0000 0004 0512 597XDepartment of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Nick Meier
- grid.475435.4Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Wolfgang Leistner
- grid.475435.4Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Johan Mårtensson
- grid.4714.60000 0004 1937 0626Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Centre for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Anders Perner
- grid.475435.4Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark ,grid.512292.fCollaborations for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Maj-Brit Nørregaard Kjær
- grid.475435.4Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark ,grid.512292.fCollaborations for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marie Warrer Munch
- grid.475435.4Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark ,grid.512292.fCollaborations for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Martin Dahlberg
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden ,grid.416648.90000 0000 8986 2221Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden ,grid.416648.90000 0000 8986 2221Department of Anaesthesia and Intensive Care, Södersjukhuset, Sjukhusbacken 10, SE-118 83 Stockholm, Sweden ,grid.512292.fCollaborations for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden ,grid.416648.90000 0000 8986 2221Department of Anaesthesia and Intensive Care, Södersjukhuset, Sjukhusbacken 10, SE-118 83 Stockholm, Sweden ,grid.512292.fCollaborations for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Hojker M, Tršan J, Tršan U, Gale A, Jerman A, Košuta D. Predictive value of inflammatory and coagulation biomarkers for venous thromboembolism in Covid-19 patients. Clin Hemorheol Microcirc 2023; 83:387-395. [PMID: 36683498 DOI: 10.3233/ch-221664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The predictive value of coagulation markers for venous thromboembolism (VTE) in Covid-19 patients has been investigated with conflicting results. OBJECTIVE Our aim was to investigate the correlation between biomarkers and VTE and the predictive value of D-dimer for VTE in hospitalized Covid-19 patients. METHODS Complete blood count, inflammatory and coagulation biomarkers at admission were collected. VTE was defined as diagnosed pulmonary embolism or deep vein thrombosis. Events were defined as in-hospital death or ICU admission. Predictors of VTE were identified with Pearson prediction models. A ROC curve was constructed to assess the predictive value of D-dimer. RESULTS 1651 participants were included, 111 VTE were identified. Events incidence was higher in the VTE group (49.5% vs 28.2%, p < 0.001). Neutrophil-lymphocyte ratio (NLR, 0.001; 95% CI 0.000-0.002; p 0.019) and D-dimer (0.00005; 95% CI 0.00002-0.00008; p < 0.001), Geneva score (0.026; 95% CI 0.012-0.040; p < 0.001) and Wells score (0.047; 95% CI 0.033-0.061; p < 0.001) were associated with VTE. D-dimer had a goor predictive value for VTE (ROC area 0.85, 95% CI 0.816-0.893), with an optimal cut-off value of 2677μg/L (Youden index of 0,602). CONCLUSIONS Among coagulation biomarkers D-dimer had the best predictive value for VTE, but higher cut-off values should be used in Covid-19.
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Affiliation(s)
- Marta Hojker
- University Medical Centre Ljubljana, Department of Orthopaedic Surgery, Ljubljana, Slovenia.,University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia
| | - Jure Tršan
- University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia.,University Medical Centre Ljubljana, Department of Vascular Diseases, Ljubljana, Slovenia
| | - Uroš Tršan
- University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia
| | - Ana Gale
- University Medical Centre Ljubljana, Department of Dermatovenereology, Ljubljana, Slovenia
| | - Alexander Jerman
- University Medical Centre Ljubljana, Department of Nephrology, Ljubljana, Slovenia
| | - Daniel Košuta
- University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia.,University Medical Centre Ljubljana, Department of Vascular Diseases, Ljubljana, Slovenia
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Kangro K, Wolberg AS, Flick MJ. Fibrinogen, Fibrin, and Fibrin Degradation Products in COVID-19. Curr Drug Targets 2022; 23:1593-1602. [PMID: 36029073 DOI: 10.2174/1389450123666220826162900] [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: 03/29/2022] [Revised: 05/31/2022] [Accepted: 06/15/2022] [Indexed: 01/25/2023]
Abstract
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the highly pathogenic and highly transmissible human coronavirus that is the causative agent for the worldwide COVID-19 pandemic. COVID-19 manifests predominantly as a respiratory illness with symptoms consistent with viral pneumonia, but other organ systems (e.g., kidney, heart, brain) can also become perturbed in COVID-19 patients. Accumulating data suggest that significant activation of the hemostatic system is a common pathological manifestation of SARS-CoV-2 infection. The clotting protein fibrinogen is one of the most abundant plasma proteins. Following activation of coagulation, the central coagulation protease thrombin converts fibrinogen to fibrin monomers, which selfassemble to form a matrix, the primary structural component of the blood clot. Severe COVID-19 is associated with a profound perturbation of circulating fibrinogen, intra- and extravascular fibrin deposition and persistence, and fibrin degradation. Current findings suggest high levels of fibrinogen and the fibrin degradation product D-dimer are biomarkers of poor prognosis in COVID-19. Moreover, emerging studies with in vitro and animal models indicate fibrin(ogen) as an active player in COVID-19 pathogenesis. Here, we review the current literature regarding fibrin(ogen) and COVID-19, including possible pathogenic mechanisms and treatment strategies centered on clotting and fibrin(ogen) function.
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Affiliation(s)
- Kadri Kangro
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Matthew J Flick
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Global thrombosis test for assessing thrombotic status and efficacy of antithrombotic diet and other conditions. Future Sci OA 2022; 8:FSO788. [PMID: 35251699 PMCID: PMC8890116 DOI: 10.2144/fsoa-2021-0086] [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: 07/15/2021] [Accepted: 01/10/2022] [Indexed: 11/23/2022] Open
Abstract
Because of the high mortality from myocardial infarction and stroke, there is a great demand for finding novel methods of diagnosis, prevention and treatment of these diseases. Most of the current tests measure important determinants of thrombosis such as platelet function, coagulation and fibrinolysis in isolation; therefore, a global test measuring the actual thrombotic status would be more useful in clinical conditions. We obtained considerable experience by using the global thrombosis test, which determines the actual thrombotic status by taking into account the measured platelet reactivity, coagulation and fibrinolytic activities. In animal experiments, we found significant correlation between the ex vivo global thrombosis test measurements and the in vivo thrombotic status. The published evidence for the benefit of an antithrombotic diet with regular physical exercise is also described. There is a great concern in the general population how to detect the risk of thrombotic events and prevent the high mortality from stroke, myocardial infarction, sudden death and cancer-associated thrombosis. Our experience on antithrombotic fruits and vegetables intake and regular exercise assessed by the global thrombosis test suggested a potentially unique way of preventing these life-threatening diseases. In addition, global thrombosis testing may offer some benefit in detecting risk of thrombotic of forthcoming thrombotic events in cancer and COVID-19 virus-infected patients.
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Korevaar DA, Aydemir I, Minnema MW, Azijli K, Beenen LF, Heijmans J, van Es N, Al Masoudi M, Meijboom LJ, Middeldorp S, Nanayakkara PW, Meijer RI, Bonta PI, van Es J. Routine screening for pulmonary embolism in COVID-19 patients at the emergency department: impact of D-dimer testing followed by CTPA. J Thromb Thrombolysis 2021; 52:1068-1073. [PMID: 34160744 PMCID: PMC8221091 DOI: 10.1007/s11239-021-02508-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 12/19/2022]
Abstract
COVID-19 patients have increased risk of pulmonary embolism (PE), but symptoms of both conditions overlap. Because screening algorithms for PE in COVID-19 patients are currently lacking, PE might be underdiagnosed. We evaluated a screening algorithm in which all patients presenting to the ED with suspected or confirmed COVID-19 routinely undergo D-dimer testing, followed by CT pulmonary angiography (CTPA) if D-dimer is ≥ 1.00 mg/L. Consecutive adult patients presenting to the ED of two university hospitals in Amsterdam, The Netherlands, between 01-10-2020 and 31-12-2020, who had a final diagnosis of COVID-19, were retrospectively included. D-dimer and CTPA results were obtained. Of 541 patients with a final diagnosis of COVID-19 presenting to the ED, 25 (4.6%) were excluded because D-dimer was missing, and 71 (13.1%) because they used anticoagulation therapy. Of 445 included patients, 185 (41.6%; 95%CI 37.0–46.3) had a D-dimer ≥ 1.00 mg/L. CTPA was performed in 169 of them, which showed PE in 26 (15.4%; 95%CI 10.3–21.7), resulting in an overall detection rate of 5.8% (95%CI 3.9–8.4) in the complete study group. In patients with and without PE at CTPA, median D-dimer was 9.84 (IQR 3.90–29.38) and 1.64 (IQR 1.17–3.01), respectively (p < 0.001). PE prevalence increased with increasing D-dimer, ranging from 1.2% (95%CI 0.0–6.4) if D-dimer was 1.00–1.99 mg/L, to 48.6% (95%CI 31.4–66.0) if D-dimer was ≥ 5.00 mg/L. In conclusion, by applying this screening algorithm, PE was identified in a considerable proportion of COVID-19 patients. Prospective management studies should assess if this algorithm safely rules-out PE if D-dimer is < 1.00 mg/L.
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Affiliation(s)
- Daniël A Korevaar
- Department of Respiratory Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Ilayda Aydemir
- Department of Respiratory Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Respiratory Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Maartje W Minnema
- Section Emergency Medicine, Emergency Department, Amsterdam Cardiovascular Sciences, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Kaoutar Azijli
- Section Emergency Medicine, Emergency Department, Amsterdam Cardiovascular Sciences, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Ludo F Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jarom Heijmans
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands
| | - Mohanad Al Masoudi
- Section Emergency Medicine, Emergency Department, Amsterdam Cardiovascular Sciences, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud UMC, Nijmegen, The Netherlands
| | - Prabath W Nanayakkara
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Rick I Meijer
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands
| | - Peter I Bonta
- Department of Respiratory Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Josien van Es
- Department of Respiratory Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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