Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

American Society for Metabolic and Bariatric Surgery: postoperative care pathway guidelines for Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways and guidelines help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety (QIPS) Committee of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG), preoperative care of patients undergoing Roux-en-Y gastric bypass (RYGB), and most recently, intraoperative care of patients undergoing RYGB.

OBJECTIVES

This current RYGB care pathway guideline was created to address postoperative care guidance.

SETTING

Academic Health Center.

METHODS

For this systematic review, PubMed queries were performed from January 1979 to December 2019. Follow-up queries were performed from January 2020 to July 2024. Peer-reviewed publications were reviewed according to the level of evidence (LoE) regarding specific key questions developed by the QIPS Committee and working group for this pathway.

RESULTS

Evidence-based recommendations are made for the postoperative care of patients undergoing RYGB, including recommendations for early postoperative care, postoperative medication management, and long-term postoperative surveillance.

CONCLUSIONS

This document may provide a structure to providers based on current evidence for the postoperative care of patients with overweight or obesity undergoing RYGB.

Management of pharmacotherapy in lung transplant candidates

PURPOSE OF REVIEW

Lung transplantation is a common treatment for end-stage lung disease (ESLD). Patients present to lung transplantation evaluation on various medications that could impact their candidacy and posttransplant course. In this review, we will discuss pretransplant optimization of pharmacotherapy to minimize complications while waiting for transplant and increase posttransplant success. We will also discuss important considerations for posttransplant immunosuppression, antimicrobial prophylaxis, and complex drug interactions.

RECENT FINDINGS

Prior to lung transplantation, several medications should be optimized to promote posttransplant success including minimization of corticosteroids, opioids, and benzodiazepines. Lung transplantation candidates should be up to date on vaccinations. Most medications for ESLD are well tolerated to continue up until the point of transplant including antifibrotics, CFTR modulators, and pulmonary vasodilators. Mammalian target of rapamycin inhibitors and other immunosuppressants may need to be stopped or minimized before lung transplantation to minimize posttransplant infection and would healing complications. Medications that increase risk of posttransplant bleeding, thrombosis, or aspiration should be stopped prior to listing.

SUMMARY

In this article, we discuss management of pharmacotherapy for lung transplantation candidates to minimize posttransplant complications. Changes in medications for ESLD should be done cautiously to prevent worsening of native disease while waiting for lung transplantation.

A comparison of the effects of direct oral anticoagulants versus vitamin K antagonists and antiplatelet agents on the timing and outcomes of hip fracture surgery in patients older than 65 years: the ORTHO-GER-DOAC study

INTRODUCTION

The use of direct oral anticoagulants (DOACs) may delay surgery in older hip fracture patients.

AIM

To assess whether preoperative DOAC activity measurement enables surgery within 48 h in hip fracture patients at a similar prevalence compared to patients receiving other antithrombotics or no antithrombotics.

METHODS

A retrospective observational cohort study of hip fracture patients older than 65 years admitted to three Orthogeriatrics units in Italy from 2015 to 2022 was conducted. At admission, demographical and comorbid conditions were recorded, and antithrombotics were stopped. Patients on vitamin K antagonists (VKAs) underwent international normalized ratio (INR) assessments and received vitamin K to achieve an INR below 1.5. Patients receiving DOACs who were enrolled before 2018 underwent daily drug testing, and surgery was performed only after DOAC levels were near or below trough levels. Hours from hospital admission to surgery, perioperative total blood loss, major bleeding and mortality at 90 days were recorded.

RESULTS

Amongst the 747 patients (median age 85 years; M/F: 192/555), the prevalence of surgery within 48 h was significantly lower amongst patients receiving DOACs (47%) than amongst patients receiving antiplatelet agents (77%) and patients receiving no antithrombotic agents (73%). Preoperative DOAC measurements significantly delayed the time to surgery (median 51 vs. 42 h: P < 0.05). The major bleeding and mortality rates at 90 days did not differ based on the type of antithrombotics used. The degree of perioperative blood loss was greater in patients receiving DOACs, regardless of drug measurement, than in patients taking other antithrombotics.

CONCLUSIONS

DOAC measurement may delay hip fracture surgery, as even low presurgical levels of DOACs are associated with greater perioperative blood loss.

Cataracts: A Review

Importance

Age-related cataract, defined as progressive opacification or clouding of the eye's natural lens, is a leading cause of visual disability and blindness. Cataract surgery is one of the most commonly performed procedures in high-income countries. More than 3.5 million cataract operations are performed annually in the US.

Observations

Older age is the primary risk factor for cataracts, with approximately two-thirds of the population older than 80 years affected. As the population ages, the number of people with cataracts in the US is expected to increase to 50 million by 2050. Additional risk factors for cataracts include a hereditary or genetic predisposition, certain medications (corticosteroids), ocular trauma, significant UV exposure or radiation therapy, and certain medical conditions such as uncontrolled diabetes, retinitis pigmentosa, Down syndrome, and congenital rubella. Painless, progressive blurring of vision and visual glare are common symptoms of cataracts. Cataracts are diagnosed during an eye examination by an ophthalmologist or optometrist. Surgery to remove the cataract and implant a permanent intraocular lens (IOL) is indicated if visual impairment impedes activities of daily living and is associated with lower rates of falls (>30%) and dementia (20%-30%). Most cataract operations are performed with topical anesthesia. Therefore, patients do not require preoperative general medical testing such as bloodwork or electrocardiogram, and do not need to discontinue anticoagulants for cataract surgery. Systemic α1-adrenergic antagonists for symptomatic benign prostatic hyperplasia, such as tamsulosin, increase the risk of surgical complications and some ophthalmologists temporarily discontinue the drug preoperatively. Intraocular antibiotics, such as moxifloxacin or cefuroxime, delivered intraoperatively have reduced the rates of sight-threatening postsurgical endophthalmitis from 0.07% to 0.02%. In addition to reversing and preventing progressive vision loss, cataract surgery can reduce dependence on eyeglasses. These optional refractive benefits are achieved with advanced technology IOL designs, such as multifocal IOLs. However, multifocal and other advanced technology refractive IOLs are associated with increased costs that are not covered by medical insurance.

Conclusions and Relevance

Cataracts are common among older adults and may cause visual disability and blindness without treatment. Cataract surgery reverses and prevents progressive vision loss, and advanced technology lens implants facilitate reduced dependence on eyeglasses.

Continuous use of direct oral anticoagulants during and after simple and surgical tooth extractions: a prospective clinical cohort study

BACKGROUND

No consistent approach to the management of direct oral anticoagulants (DOACs) during and after oral surgery has been established. Thus, DOACs may be unnecessarily discontinued, raising the potential risk of life-threatening thromboembolism. To address the inconsistency in this approach, our study assessed the risk of bleeding and other complications in patients who continue to use DOACs during and after simple and surgical tooth extractions.

METHODS

Between May 2016 and December 2023, this prospective study recruited patients aged 18 years or older who were receiving a DOAC or warfarin and were in need of simple or surgical extractions of one or more teeth. Local haemostatic agents were being used to control bleeding. Patients were instructed to manage minor postoperative bleeding at home by biting down on gauze soaked in tranexamic acid for at least 30 min. After surgery, all patients were followed for 7 days. The chi-squared test compared dichotomous variables; the two-sample t-test, continuous variables; logistic regressions, dichotomous outcomes; and linear regressions, continuous outcomes.

RESULTS

In all, 354 teeth were extracted from 160 patients receiving DOACs and 56 patients receiving warfarin. The incidence of any type of postoperative bleeding was 27% in patients receiving DOACs and 37% in those receiving warfarin (OR 0.66, 95% CI: 0.28-1.57; p = 0.35). Most patients were able to manage any bleeding at home themselves. Clinically relevant bleeding necessitating prompt evaluation or a secondary surgical intervention by a dentist or healthcare professional occurred in 3% of patients receiving DOACs and 11% of patients receiving warfarin (OR 0.30, 95% CI: 0.08-1.06; p = 0.06). No reports of major bleeding requiring hospitalization or blood transfusion were found. Perioperative bleeding volume was comparable between the two groups.

CONCLUSIONS

Patients receiving DOACs without interruption during surgery may have a lower risk of bleeding than those on warfarin. Patients may safely continue to use DOACs during and after simple and surgical extractions. This eliminates the potentially higher risk of serious thromboembolic events that are associated with a pause in anticoagulant therapy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT04662515). Retrospectively registered 4 December 2020.

Impact of Drugs Used in Intensive Care on Routine Coagulation Testing

Coagulation testing is commonly used in the intensive care unit (ICU) to monitor and manage the hemostatic balance, assess bleeding risk, and guide anticoagulant therapy. Routine tests used for this purpose include prothrombin time, activated partial thromboplastin time, fibrinogen, and anti-Xa assays. Some of the drugs commonly used in critically ill patients may influence coagulation assays by interacting in vitro with reagents or in vivo with coagulation pathways, thus altering the coagulation cascade and the fibrinolytic pathway. While the pharmacological effects of drugs on coagulation are usually documented, to our knowledge, no comprehensive review article has been published to date. In this review, we have conducted a critical analysis of the literature to define: (1) the impact of hydroxocobalamin, intravenous lipid emulsion, and propofol on chromogenic assays; (2) the impact of PEGylated compounds, emicizumab, recombinant activated factor VII, antibiotics, and sugammadex on chronometric assays; (3) the challenges associated with bridging anticoagulation in the ICU as well as the effect of N-acetylcystein, serotonin reuptake inhibitors, and tramadol on the hemostasis system. For each drug, we specify the routine coagulation assay that is impacted, whether this is linked to an in vitro interference or an in vivo effect, and the potential consequences on patient management.

Perioperative aspirin and coronary artery bypass graft surgery: An updated meta-analysis of randomized controlled trials

BACKGROUND

The decision to continue aspirin before elective coronary artery bypass graft surgery remains contentious because of competing thrombotic and bleeding risks. We performed a contemporary systematic review and meta-analysis to compare outcomes between patients undergoing coronary artery bypass grafting who stopped and continued aspirin before surgery.

METHODS

PubMed, MEDLINE, and CENTRAL databases were searched from inception to 4 October 2023 for randomized controlled trials comparing patients undergoing coronary artery bypass grafting who continued preoperative aspirin with those who discontinued before surgery. Studies with cointervention arms and multivariable-adjusted or propensity matched observational studies were excluded. Summary odds ratios were calculated using a random effects model for dichotomous and continuous variables. Subgroup and sensitivity analyses were conducted in order to explore sources of heterogeneity.

RESULTS

Fifteen eligible randomized controlled trials were included with a total of 6,188 patients. Patients who continued aspirin demonstrated no significant difference in all-cause mortality (odds ratio, 1.37; confidence interval, 0.81-2.33), perioperative myocardial infarction (odds ratio, 0.81; confidence interval, 0.55-1.18), and postoperative blood loss (mean difference, 66.12 mL; confidence interval, -1.45 to 133.69). No significant difference was observed between low-dose and greater doses of aspirin. There was minimal heterogeneity amongst included studies (I2 = 0%, P = .97, I2 = 33%, P = .13, and I2= 76, P = .06, respectively). Studies were of low methodologic quality according to Cochrane Risk of Bias for Randomized Trials.

CONCLUSIONS

This largest to-date systematic review and meta-analysis found no significant difference for risk of all-cause mortality, perioperative myocardial infarction, and postoperative bleeding between patients continuing and stopping aspirin before coronary artery bypass grafting.

Association of Anaesthetists guidelines: the use of blood components and their alternatives

BACKGROUND

The administration of blood components and their alternatives can be lifesaving. Anaemia, bleeding and transfusion are all associated with poor peri-operative outcomes. Considerable changes in the approaches to optimal use of blood components and their alternatives, driven by the findings of large randomised controlled trials and improved haemovigilance, have become apparent over the past decade. The aim of these updated guidelines is to provide an evidence-based set of recommendations so that anaesthetists and peri-operative physicians might provide high-quality care.

METHODS

An expert multidisciplinary, multi-society working party conducted targeted literature reviews, followed by a three-round Delphi process to produce these guidelines.

RESULTS

We agreed on 12 key recommendations. Overall, these highlight the importance of organisational factors for safe transfusion and timely provision of blood components; the need for protocols that are targeted to different clinical contexts of major bleeding; and strategies to avoid the need for transfusion, minimise bleeding and manage anticoagulant therapy.

CONCLUSIONS

All anaesthetists involved in the care of patients at risk of major bleeding and peri-operative transfusion should be aware of the treatment options and approaches that are available to them. These contemporary guidelines aim to provide recommendations across a range of clinical situations.

Outcomes of periprocedural continuation vs interruption of oral anticoagulation in transcatheter aortic valve replacement

BACKGROUND

Up to one-third of patients undergoing transcatheter aortic valve replacement (TAVR) have an indication for oral anticoagulation (OAC), primarily due to underlying atrial fibrillation. The optimal approach concerning periprocedural continuation vs interruption of OAC in patients undergoing TAVR remains uncertain, which our meta-analysis aims to address.

AIM

To explore safety and efficacy outcomes for patients undergoing TAVR, comparing periprocedural continuation vs interruption of OAC therapy.

METHODS

A literature search was conducted across major databases to retrieve eligible studies that assessed the safety and effectiveness of TAVR with periprocedural continuous vs interrupted OAC. Data were pooled using a random-effects model with risk ratio (RR) and their 95% confidence interval (CI) as effect measures. All statistical analyses were conducted using Review Manager with statistical significance set at P < 0.05.

RESULTS

Four studies were included, encompassing a total of 1813 patients with a mean age of 80.6 years and 49.8% males. A total of 733 patients underwent OAC interruption and 1080 continued. Stroke incidence was significantly lower in the OAC continuation group (RR = 0.62, 95%CI: 0.40-0.94; P = 0.03). No significant differences in major vascular complications were found between the two groups (RR = 0.95, 95%CI: 0.77-1.16; P = 0.60) and major bleeding (RR = 0.90, 95%CI: 0.72-1.12; P = 0.33). All-cause mortality was non-significant between the two groups (RR = 0.83, 95%CI: 0.57-1.20; P = 0.32).

CONCLUSION

Continuation of OAC significantly reduced stroke risk, whereas it showed trends toward lower bleeding and mortality that were not statistically significant. Further large-scale studies are crucial to determine clinical significance.

The impact of preoperative maintaining antithrombotic therapy in patients undergoing non-coronary endovascular interventions

BACKGROUND

Antithrombotic medications, including antiplatelet and anticoagulant therapies, are widely used to prevent thromboembolic events in patients with cardiovascular diseases. It is common for patients on antithrombotic medications to undergo endovascular interventions though potential complications remain unclear. This study investigated the impact of continuing antithrombotic medications before endovascular interventions on perioperative clinical outcomes, particularly intraoperative blood transfusion.

METHODS

This retrospective cohort study included patients who underwent endovascular interventions between January 2019 and December 2022. Patients were divided into four groups based on the preoperative antithrombotic medications: (1) those not receiving any antithrombotic therapy; (2) those receiving single antiplatelet therapy; (3) those receiving dual antiplatelet therapy; (4) those receiving anticoagulant therapy. Clinical outcomes, including blood transfusion, hematoma and pseudoaneurysm, were analyzed using multivariate logistics regression. Subsequently, patients were stratified based on whether they received blood transfusion. All-cause mortality, adverse cardiovascular events and infectious events were used to evaluate the impact of blood transfusion.

RESULTS

A total of 5743 patients were included, with a mean age of 67.08 ± 14.27 years, and 69.81% of them were male. Common underlying conditions included hypertension (60.48%), vascular disease (28.75%), diabetes mellitus (22.60%), congestive heart failure (6.39%), and immune disease (4.21%). Compared to patients not receiving any antithrombotic medications, those undergoing dual antiplatelet therapy or anticoagulant therapy exhibited an increased risk of requiring blood transfusion (OR: 2.05, 95%CI: 1.30-3.23; OR: 1.92, 95%CI: 1.22-3.03). Subgroup analysis indicated that the risk of blood transfusion varied depending on the type of anesthesia, number of puncture sites and renal function, with a significant interaction (P < 0.05). Patients who required blood transfusion had a significantly higher rate of one-year all-cause mortality (HR: 2.18, 95% CI: 1.10-4.32) and three-month infectious events (HR: 4.92, 95% CI: 1.72-14.06).

CONCLUSIONS

Preoperative maintaining dual antiplatelet or anticoagulant therapy increased the risk of blood transfusion in endovascular interventions. Blood transfusion was independently associated with increased risk of all-cause mortality and infectious events. These findings suggested the need for tailored perioperative management of antithrombotic therapy in patients undergoing endovascular interventions.

Perioperative management of direct oral anticoagulants in patients having a high-bleed-risk surgery or neuraxial procedure: the Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE)-2 pilot randomized trial

BACKGROUND

There is uncertainty about the perioperative management of patients who are receiving a direct oral anticoagulant (DOAC) and require elective high-bleed-risk surgery, including those who are undergoing a neuraxial or deep peripheral nerve block procedure.

OBJECTIVES

The objectives of this pilot trial were to provide preliminary data as to pre-operative residual DOAC levels with different management strategies andro assess the feasibility of a larger trial.

METHODS

The Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE)-2 pilot trial was a proof-of-concept, open-label, randomized controlled trial that assessed the feasibility of comparing perioperative DOAC management using an American Society of Regional Anesthesia (ASRA)-based or PAUSE-based approach in patients with atrial fibrillation who needed an elective high-bleed-risk surgery/procedure and/or any neuraxial anesthesia/procedure.

RESULTS

There were 159 patients enrolled (86 on apixaban, 12 on dabigatran, and 61 on rivaroxaban), of whom 141 had preoperative DOAC-level testing done. The median (IQR) residual DOAC level was 19 (19-24) ng/mL in the ASRA group and 20 (19-24) ng/mL in the PAUSE group (standardized difference = -0.02). The percentage of patients in the ASRA and PAUSE groups with preoperative residual DOAC levels < 30 ng/mL was 95.6% and 94.4%, respectively; the percentage with residual DOAC levels of 30 to 50 ng/mL was 1.4% and 2.8%, respectively, and the percentage with levels > 50 ng/mL was 2.9% and 2.8%, respectively.

CONCLUSION

In this pilot trial, we found that recruitment of DOAC-treated patients who needed an elective high-bleed-risk surgery or neuraxial procedure was feasible and that preoperative residual DOAC levels appeared similar according to ASRA-based and PAUSE-based management approaches, providing the foundation for a larger trial comparing ASRA- and PAUSE-based perioperative DOAC management.

Who are we bridging? Description of warfarin patients receiving injectable bridging therapy

PURPOSE

The evidence guiding the decision to provide injectable anticoagulant bridging therapy during periods of subtherapeutic warfarin anticoagulation is sparse. This study aims to identify the types of patients currently bridged within an academic medical center's Thrombosis Service, to highlight patient populations for future study of bridging outcomes.

METHODS

This descriptive cohort study included patients taking warfarin managed by University of Utah Health Thrombosis Service who received outpatient enoxaparin bridging between January 1 and December 31, 2022. Anticoagulation indication, reason for bridging, and type of procedure were validated via manual chart review.

RESULTS

During the one-year study period, 181 unique patients (9.4 % of the service's total warfarin population) experienced 244 bridging episodes, mostlyin the periprocedural setting (67.6 %) for gastrointestinal-type procedures (39.4 %). The most common anticoagulation indications in all bridged patients were antiphospholipid syndrome (APS) (23.2 %), venous thromboembolism (VTE) (21.5 %), or a mechanical mitral valve plus another indication (13.3 %). Most bridging episodes for VTE occurred >3 months from the acute event, with the rationale for bridging including breakthrough VTE (31 %) or APS (23 %). Just over one-half of bridged patients fit the guideline-recommended criteria for high thrombotic risk, and just over one-third were low-moderate thrombotic risk.

CONCLUSIONS

In this one-year outpatient study, warfarin patients received enoxaparin bridging most commonly due to a gastrointestinal procedural interruption in the setting of APS, VTE with a prior breakthrough thrombotic event, or mechanical mitral valve. Just over one-third of bridged patients were guideline-classified as low-moderate thrombotic risk, indicating these populations may warrant further investigation or bridging de-escalation.

Safe and effective anticoagulation use: case studies in anticoagulation stewardship

Anticoagulant use is prevalent and associated with significant potential for harm. Anticoagulation stewardship practice has emerged to address care gaps and promote safe, effective, and cost-conscious anticoagulation use across health care systems. We present 4 patient cases describing common challenges in anticoagulation management: inappropriate dosing of direct oral anticoagulants, the diagnosis and management of heparin-induced thrombocytopenia, periprocedural anticoagulation management, and heavy menstrual bleeding on anticoagulation. We discuss available examples of successful stewardship programs that can address the challenges of each case, demonstrating how an investment in anticoagulation stewardship can improve patient outcomes.

Direct oral anticoagulants (DOACs) increase time to operating room without increasing postoperative hematologic complications in patients with fragility fractures of the proximal femur

INTRODUCTION

Fragility fractures of the proximal femur are common injuries with significant morbidity and mortality. The use of direct oral anticoagulant (DOAC) medications is increasing among the elderly and is associated with perioperative bleeding-related complications. The primary aim of this study was to examine how DOAC use affects surgical timing and postoperative hematologic complications in patients treated operatively for fragility fractures of the proximal femur. The effect of an institutional tranexamic acid (TXA) protocol implemented during the study period was investigated as a secondary aim.

MATERIALS AND METHODS

This was a retrospective analysis performed at a Level I trauma center. Between March 1, 2018 and April 1, 2022, 746 patients age 50 years and older who underwent surgical treatment for a fragility fracture of the femoral neck, intertrochanteric, or subtrochanteric region of the proximal femur (AO/OTA 31A, 31B, 32) and who were either on no chemical anticoagulation, warfarin, or a DOAC at the time of injury were included. The primary outcomes were time to operating room (TTOR), postoperative transfusion, 30-day venous thromboembolism (VTE), and 30-day hospital readmission. Multivariable logistic regression modeling was used to analyze the effect of anticoagulant, TXA use, and TTOR on these outcomes.

RESULTS

TTOR was increased for patients on warfarin (38.3 ± 26.1 h) or a DOAC (46.4 ± 23.4 h) compared to patients not on anticoagulation (28.0 ± 19.0 h) (p < 0.001). There was no significant difference in transfusion rates among patients not on anticoagulants (31.8 %), warfarin (43.4 %), or a DOAC (29.6 %). Multivariable regression showed a decrease in transfusion rate (OR 0.35, 95 % CI 0.23-0.53) and 30-day readmission (OR 0.31, 95 % CI 0.15-0.61) for intravenous (IV) TXA.

CONCLUSIONS

DOAC use was associated with an increase in TTOR without increased rates of transfusion, VTE, or hospital readmission in patients with fragility fractures of the proximal femur. Intravenous TXA was associated with reduced postoperative transfusion and 30-day readmission.

Minimally Invasive vs. Open Synovectomy in Rheumatoid Arthritis: Insights into Clinical Recovery, Systemic Inflammation, and Economic Impact

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by persistent synovial inflammation, leading to joint destruction and disability. Synovectomy, the surgical removal of inflamed synovial tissue, is performed when pharmacological treatments are insufficient. This study compares the clinical efficacy, systemic inflammatory response, and cost-effectiveness of minimally invasive arthroscopic synovectomy versus traditional open synovectomy in RA patients. Methods: A comparative observational study was conducted on 53 RA patients undergoing either arthroscopic (n = 30) or open synovectomy (n = 23) at "Pius Brînzeu" Timișoara County Emergency Clinical Hospital over nine years. Clinical outcomes, including pain relief (VAS), functional improvement (HAQ), complication rates, and recovery times, were assessed at baseline, 1, 3, 6, and 12 months postoperatively. Systemic inflammatory markers (CRP, IL-6, TNF-α, ESR, and fibrinogen) were measured preoperatively, at 48 h and 30 days postoperatively. A cost-effectiveness analysis evaluated direct and indirect healthcare costs. Results: Arthroscopic synovectomy demonstrated significantly faster pain reduction and functional recovery within the first three months (p < 0.001), shorter hospital stays (3.1 vs. 6.4 days, p < 0.001), and quicker returns to daily activities (14.5 vs. 22.3 days, p < 0.001) compared to open synovectomy. Inflammatory markers were significantly lower postoperatively in the arthroscopic group (p < 0.01), indicating reduced systemic inflammation. Complication rates were markedly lower in the arthroscopic group (26.66% vs. 82.60%, p < 0.001). Despite higher procedural costs, arthroscopic synovectomy proved more cost-effective due to reduced hospitalization and faster recovery. Conclusions: Arthroscopic synovectomy offers superior early postoperative outcomes, reduced systemic inflammation, and greater cost-effectiveness compared to open synovectomy, with comparable long-term joint stability. These findings support its preference as the surgical technique of choice for RA patients requiring synovectomy.

Impact of Continuation Versus Interruption of Oral Anticoagulation During TAVI on Health-Related Quality of Life

BACKGROUND

One-third of patients undergoing TAVR have a concomitant indication for oral anticoagulation. The impact of continuation as compared to interruption of oral anticoagulation during TAVR on health-related quality of life is unknown.

AIMS

To investigate the impact of continuation as compared to interruption of oral anticoagulation on health-related quality of life.

METHODS

The POPular PAUSE TAVI (Periprocedural Continuation vs. Interruption of Oral Anticoagulant Drugs during Transcatheter Aortic Valve Implantation) trial was an international, open-label, randomized, clinical trial performed at 22 European sites. Health-related quality of life was assessed using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Short Form-12 (SF-12) before, and at 1 and 3 months after TAVR.

RESULTS

A total of 8 patients were included: 431 were assigned to continuation and 427 to interruption of oral anticoagulation. Before TAVR, the mean overall KCCQ summary score was 53.6 (±26.0). At 1 month, the mean change in KCCQ summary score as compared to baseline was +11.4 points (95% confidence interval [CI] 8.0-14.8) in the continuation group and +12.2 points (95% CI 8.8-15.6) in the interruption group (difference -0.7 points; 95% CI -4.6 to 3.1). At 3 months, the mean change was +11.0 points (95% CI 7.3-14.6) versus +13.8 points (95% CI 10.2-17.4), respectively (difference -2.8 points; 95% CI -7.1 to 1.5). Mean changes in SF-12 physical and mental component summary scores showed no differences between both groups at 1 and 3 months after TAVR.

CONCLUSIONS

In patients undergoing TAVR with a concomitant indication for oral anticoagulation, continuation as compared to interruption of oral anticoagulation during TAVR did not significantly impact health-related quality of life up to 3 months after TAVR.

Influence of Direct Oral Anticoagulant Levels and Thrombin Generation on Postoperative Bleeding [SONAR]: A Nested Case-Control Study

BACKGROUND

 A direct oral anticoagulant (DOAC) concentration threshold above which an impact on surgical hemostasis starts to occur is unknown. Thrombin generation assays (TGAs) provide a measure of the coagulation phenotype. This study aimed to determine whether preoperative TGA parameters are associated with postoperative bleeding, and whether this is partly due to residual DOAC levels.

MATERIALS AND METHODS

 We conducted a nested case-control study using samples from apixaban/rivaroxaban-treated patients with atrial fibrillation from the PAUSE (Perioperative Anticoagulation Use for Surgery Evaluation) perioperative study. Cases were participants with postoperative major or clinically relevant nonmajor bleeding; controls were participants without bleeding. DOAC levels were measured using a chromogenic anti-Xa assay (BIOPHEN DiXaI; rivaroxaban/apixaban calibrators). TGA parameters were measured using calibrated automated thrombography.Generalized linear mixed models and causal mediation analyses were used to evaluate the relationship between DOAC levels, TGA parameters, and bleeding.

RESULTS

 Forty eight cases were matched to 474 controls. Residual DOAC levels were higher in cases than controls (p¼0.03) and each TGA parameter was correlated with residual DOAC levels (p<0.05). A longer lag time (LT; odds ratio [OR]¼1.319 per minute [95% confidence interval [CI]: 1.077-1.617]) and time-to-peak (TTP; OR¼1.154 per minute [95% CI: 1.028-1.296]) were associated with an increased odds of bleeding; higher peak (OR¼0.994 per nM [95% CI: 0.989-0.998]) and mean velocity rate index (mVRI; OR¼0.986 per nM/min [95% CI: 0.976-0.996]) were associated with a lower odds of bleeding. The effect of apixaban/rivaroxaban levels on bleeding was mediated by altered TGA parameters (LT, TTP, peak, mVRI).

CONCLUSION

 These findings support a measurable effect from low residual DOAC levels on thrombin generation and suggest a causal contribution of both toward bleeding.

Perioperative Factor Xa Inhibitor Discontinuation for Patients Undergoing Procedures With Minimal or Low Bleeding Risk

Importance

Discontinuation of oral anticoagulant treatment is common in clinical practice due to concerns about bleeding, even for procedures with minimal to low bleeding risk.

Objective

To explore whether perioperative discontinuation of factor Xa inhibitors is associated with major bleeding and thromboembolic events in patients with atrial fibrillation (AF) undergoing procedures with minimal to low bleeding risk.

Design, Setting, and Participants

This prospective, multicenter, single-arm cohort study conducted in Korea included patients with AF who planned to undergo a procedure with minimal to low bleeding risk between September 25, 2020, and April 5, 2024.

Exposure

The PERIXa (Perioperative Factor Xa Inhibitor Discontinuation in Patients With Atrial Fibrillation Undergoing Minimal to Low Bleed Risk Procedures) protocol recommending giving the last dose of factor Xa inhibitor (ie, apixaban, edoxaban, or rivaroxaban) 24 hours before the procedure (ie, endoscopy, dental procedure, or ocular surgery) and restarting treatment with the inhibitor the next day.

Main Outcomes and Measures

The primary outcome was major bleeding, and the secondary outcome included a composite of thromboembolic events 30 days after the index procedure with minimal to low bleeding risk.

Results

In total, 1902 patients were included in the modified intention-to-treat analysis set encompassing all patients who underwent the intended procedure (mean [SD] age, 70.4 [8.8] years; 1135 [59.7%] male; mean [SD] CHA2DS2-VASc [congestive heart failure, hypertension, age 75 years or older, diabetes, stroke, vascular disease, age 65-74 years, and female sex; range, 0-9, with higher scores indicating higher risk of stroke] score, 2.8 [1.3]; mean [SD] HAS-BLED [hypertension, kidney or liver disease, stroke history, prior bleeding, unstable international normalized ratio, age >65 years, and drug or alcohol use; range, 0-9, with higher scores indicating higher risk of bleeding] score, 1.6 [0.7]). Among them, 921 (48.4%) were receiving apixaban, 616 (32.4%) were receiving edoxaban, and 365 (19.2%) were receiving rivaroxaban. Of the total procedures, 948 (49.8%) were endoscopy, 820 (43.1%) were dental procedures, and 120 (6.3%) were ocular surgery. The 30-day event rate of major bleeding was 0.1% (n = 2), and there were no composite thromboembolic events. The results were consistent in the per-protocol analysis, and no differences were observed by procedure category or factor Xa inhibitor type.

Conclusions and Relevance

In this cohort study, patients with AF receiving a factor Xa inhibitor and undergoing a procedure with minimal to low bleeding risk had low rates of major bleeding and thromboembolism when following the standardized PERIXa protocol for perioperative management of oral anticoagulant treatment, suggesting that this may be a safe and reasonable option for this patient population.

Outcomes and Current State of Deep Inferior Epigastric Perforator Flap Surgery in Peru and Mexico

Background

In developing countries, breast reconstruction has multiple barriers, especially related to microsurgical procedures. Our aim was to describe the characteristics and outcomes of patients who underwent deep inferior epigastric artery perforator (DIEP) flap in 2 Latin American countries (Peru and Mexico) performed by recent postgraduate microsurgery fellows.

Methods

A retrospective study of a case series of breast cancer patients who underwent DIEP flap surgery in 5 surgery centers in 2 different countries, Peru and Mexico, was conducted.

Results

A total of 45 female patients were included, the mean age was 47.62 years with a median body mass index of 24.91 kg/m2. The majority of patients had a presurgical diagnosis of mastectomy (91.1%), whereas 8.9% had chronic radiodermatitis. Moreover, the most common reason for surgical intervention was breast reconstruction after breast cancer surgery (88.9%). The median operative time and length of hospital stay were 8 hours (range 3-14 h) and 6 days (range 3-21 d), respectively. Twenty percent of patients required blood transfusions, 24.4% had venous congestion, and 15.6% presented wound dehiscence. Moreover, 9 (33.3%) patients required reoperation and 6 required salvage procedures (15.6%).

Conclusions

Due to the multiple healthcare barriers in these countries, a very low number of DIEP flaps are performed in Peru and Mexico. Outcomes were worse in Peru compared with Mexico, with complication rates similar to those of other Latin American countries but higher than those of interventions performed in more experienced hands in the United States and Europe.

Anesthetic and Perioperative Considerations for Convergent Procedure for Atrial Fibrillation: A Retrospective Observational Cohort Study

OBJECTIVE

To summarize anesthetic and perioperative considerations in patients undergoing the convergent procedure for atrial fibrillation (AF).

DESIGN

Retrospective observational study.

SETTING

A single quaternary teaching hospital.

PARTICIPANTS

Adult patients with AF undergoing the convergent procedure before January 2024.

INTERVENTIONS

Retrospective chart review.

MEASUREMENTS/MAIN RESULTS

The study cohort comprised 40 patients, including 35 patients with persistent longstanding AF. The mean age was 64 (SD, 6) years, and 33 patients (83%) were male. Common comorbidities included obesity (n = 27; 68%), obstructive sleep apnea (n = 29; 73%), history of tachycardia-mediated cardiomyopathy (n = 10; 25%), and significant alcohol use (n = 10; 25%). Sixteen of the 40 patients (40%) had a history of prior endocardial ablation, and 37 patients (93%) had required a cardioversion in the past. In all, 39 patients (98%) were receiving anticoagulation, and 38 (95%) were on at least 1 antiarrhythmic medication prior to the procedure. All patients received general anesthesia, inhalational in 39 patients (98%) and total intravenous in 1 patient (3%), with regional analgesia adjuncts in 36 patients (88%). All patients required lung isolation, arterial line, central venous access, and transesophageal echocardiographic monitoring. While cardiopulmonary bypass (CPB) was on standby and ready to be initiated for every patient, only 3 patients (8%) required CPB (1 planned, 2 emergent). Thirty seven of the 40 patients (93%) were extubated in the operating room, and 11 patients (28%) required intensive care unit (ICU) admission (planned or unplanned). The median ICU and hospital length of stay were 1 day and 4 days, respectively.

CONCLUSIONS

This retrospective analysis of medical records showed that many patients with recurrent AF presenting for convergent procedure carry a burden of multiple comorbidities (eg, obesity, obstructive sleep apnea), and history of unsuccessful ablations. Multistage multidisciplinary convergent procedure might be lengthy and potentially complicated and requires meticulous preparation (eg, endotracheal intubation, lung isolation, advanced cardiac monitoring, central venous access) to ensure optimal outcomes. Anesthesiologists and perioperative physicians should tailor their approach to this multimorbid population while anticipating perioperative respiratory events, rapid hemodynamic shifts, blood loss, and the possibility of CPB.

Continuation versus Interruption of Oral Anticoagulation during TAVI

BACKGROUND

One third of patients undergoing transcatheter aortic-valve implantation (TAVI) have an indication for oral anticoagulation owing to concomitant diseases. Interruption of oral anticoagulation during TAVI may decrease the risk of bleeding, whereas continuation may decrease the risk of thromboembolism.

METHODS

We conducted an international, open-label, randomized, noninferiority trial involving patients who were receiving oral anticoagulants and were planning to undergo TAVI. Patients were randomly assigned in a 1:1 ratio to periprocedural continuation or interruption of oral anticoagulation. The primary outcome was a composite of death from cardiovascular causes, stroke from any cause, myocardial infarction, major vascular complications, or major bleeding within 30 days after TAVI.

RESULTS

A total of 858 patients were included in the modified intention-to-treat population: 431 were assigned to continuation and 427 to interruption of oral anticoagulation. A primary-outcome event occurred in 71 patients (16.5%) in the continuation group and in 63 (14.8%) in the interruption group (risk difference, 1.7 percentage points; 95% confidence interval [CI], -3.1 to 6.6; P = 0.18 for noninferiority). Thromboembolic events occurred in 38 patients (8.8%) in the continuation group and in 35 (8.2%) in the interruption group (risk difference, 0.6 percentage points; 95% CI, -3.1 to 4.4). Bleeding occurred in 134 patients (31.1%) in the continuation group and in 91 (21.3%) in the interruption group (risk difference, 9.8 percentage points; 95% CI, 3.9 to 15.6).

CONCLUSIONS

In patients undergoing TAVI with a concomitant indication for oral anticoagulation, periprocedural continuation was not noninferior to interruption of oral anticoagulation during TAVI with respect to the incidence of a composite of death from cardiovascular causes, stroke, myocardial infarction, major vascular complications, or major bleeding at 30 days. (Funded by the Netherlands Organization for Health Research and Development and the St. Antonius Research Fund; POPular PAUSE TAVI ClinicalTrials.gov number, NCT04437303.).

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition)

Hemorrhagic complications associated with regional anesthesia are extremely rare. The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy reviews the published evidence since 2018 and provides guidance to help avoid this potentially catastrophic complication.The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy uses similar methodology as previous editions but is reorganized and significantly condensed. Therefore, the clinicians are encouraged to review the earlier texts for more detailed descriptions of methods, clinical trials, case series and pharmacology. It is impossible to perform large, randomized controlled trials evaluating a complication this rare; therefore, where the evidence is limited, the authors continue to maintain an 'antihemorrhagic' approach focused on patient safety and have proposed conservative times for the interruption of therapy prior to neural blockade. In previous versions, the anticoagulant doses were described as prophylactic and therapeutic. In this version, we will be using 'low dose' and 'high dose,' which will allow us to be consistent with other published guidelines and more accurately describe the dose in the setting of specific patient characteristics and indications. For example, the same 'high' dose may be used in one patient as a treatment for deep venous thrombosis (DVT) and in another patient as prophylaxis for recurrent DVT. Due to the increasing ability to obtain drug-specific assays, we have included suggestions for when ordering these tests may be helpful and guide practice. Like previous editions, at the end of each recommendation the authors have clearly noted how the recommendation has changed from previous editions.

Perioperative management of the patients with hip fracture under anticoagulant or antiaggregants treatment. Consensus recommendations from the hemostasis section of SEDAR

BACKGROUND

Antiaggregant and anticoagulant therapy complicate the management of patients with osteoporotic hip fracture.

OBJECTIVE

To homogenize and improve daily clinical practice with simple recommendations.

METHODS

The haemostasis section of SEDAR established a working group to define an action plan for the management of antiaggregated or anticoagulated patients with an osteoporotic hip fracture. The suggested recommendations are based on evidence of best practices, and have been validated by a multidisciplinary group formed by 6 specialties.

RESULTS

Early surgery reduces complications and mortality and improves patient comfort and functional recovery, with no difference in mortality between intradural and general anaesthesia.

CONCLUSION

Although uncertainties remain, it is recommended to perform surgery within 24-48 h of admission, adapting peripheral nerve blocks and type of anaesthesia (neuraxial or general) an to the haemostatic conditions. A multimodal management of antithrombotics, and the optimisation of haemostasis, haemoglobin and venous thromboprophylaxis since admission are suggested.

Management of antithrombotic therapy in patients undergoing dental procedures

A growing number of patients receiving antithrombotic therapy require dental procedures. Dental interventions in these patients can be challenging, as the risk of bleeding from the continuation of antithrombotic therapy needs to be weighed against the thromboembolic risk associated with drug interruption or de-escalation. Most minor dental procedures, including simple dental cleaning and filling, pose minimal bleeding risk, and antiplatelet or anticoagulation therapy can be continued without interruption. Local hemostatic measures, such as tranexamic mouthwash, can be used, as needed, to reduce bleeding events following these interventions. Managing antithrombotic therapy during more invasive dental interventions and oral surgeries with a higher risk of perioperative bleeding necessitates the consideration of specific factors influencing the bleeding risk and thromboembolism. In patients receiving antithrombotic therapy for primary prevention, temporary interruption is reasonable. In others, the decisions may be more complex and more nuanced. In this article, we review the current evidence for managing patients receiving oral antiplatelet or anticoagulant drugs scheduled for various dental procedures and present a practical approach for the periprocedural management of antithrombotic treatments.

Evaluation of Rivaroxaban Exposure via Anti-Xa Levels During VTE Prophylaxis in Hospitalized Patients

Rivaroxaban was FDA-approved in 2019 for venous thromboembolism (VTE) prophylaxis in acutely ill hospitalized patients. Little to no published data is available to determine the level of correlation between rivaroxaban drug concentration and UFH/LMWH calibrated anti-Xa assays at VTE prophylactic doses of rivaroxaban 10 mg daily. This study aimed to assess the anticoagulant effects of rivaroxaban prophylactic doses using LMWH calibrated anti-Xa levels at the University of Colorado Hospital (UCH). This prospective cohort study evaluated seventy-three hospitalized patients at UCH taking rivaroxaban 10 mg daily for VTE prophylaxis from June 2023 to April 2024. Patients were enrolled if they were between the ages of 18-89 years old, received rivaroxaban 10 mg daily, and had active orders for coagulation studies. A linear regression model and coefficient of determination was used to evaluate the primary outcome assessing the relationship between rivaroxaban drug concentrations and anti-Xa levels. The LMWH calibrated anti-Xa assays were strongly correlated to rivaroxaban concentrations ranging from (1-59 ng/ml) in patients receiving rivaroxaban 10 mg daily, r2 = 0.99 (P < .00001). Our data suggests that LMWH calibrated anti-Xa levels less than 1.40 IU/ml may indicate minimal anticoagulation effects for rivaroxaban 10 mg daily. The secondary outcomes assessing the relationship between rivaroxaban drug concentrations and time since administration, r2 = 0.16 (P = .049), as well as time since administration of rivaroxaban and anti-Xa activity, r2 = 0.15 (P = .066), were weakly correlated and showed a trend. Characterizing the high correlation between anti-Xa levels and rivaroxaban plasma concentrations at 10 mg daily doses, provides additional insight to rivaroxaban's anticoagulant effects in clinical practice. This can be beneficial in various clinical scenarios and has the potential to reduce the waiting time for clinical procedures.

Real world application of the 2023 ACR/EULAR antiphospholipid antibody syndrome classification criteria in a pharmacist directed anticoagulation clinic

OBJECTIVES

To determine the number of patients that met classification for antiphospholipid antibody syndrome (APS) after applying the 2023 American College of Rheumatology and the European Alliance for Associations of Rheumatology (ACR/EULAR) classification criteria, to identify reasons patients did not meet the new criteria, and determine the number of patients who were single, double, or triple positive based on laboratory criteria.

METHODS

A single center, retrospective chart review of patients with APS on anticoagulation managed by ambulatory care clinical pharmacists. Data collected included patient demographics, type of anticoagulation, and clinical and laboratory criteria for APS as defined by the 2023 ACR/EULAR criteria. Data is presented using descriptive statistics.

RESULTS

A total of 51 patients previously diagnosed with APS were included. There were 42 patients on warfarin (82.3%), 4 patients on direct oral anticoagulants (19%), 3 patients on low molecular weight heparin (5.8%), and 2 patients on fondaparinux (3.9%). Of the 51 patients, 12 (23.5%) met classification criteria, 33 (64.7%) did not meet classification criteria and 6 (11.7%) had insufficient data. Of the 27 patients that did not meet criteria, 13 patients did not meet the laboratory criteria (39.4%), 6 patients did not meet the clinical criteria (18.2%) and 14 patients did not meet both laboratory and clinical criteria (42.4%). Of the 12 patients that met classification criteria, 2 patients were triple positive (16.7%), 3 were double positive (25%), and 7 were single positive (58.3%).

CONCLUSIONS

Results from this study indicate that APS continues to be a complex disease state with challenges in diagnosis and classification. Since only a small number of patients in our clinic continued to meet the classification criteria, opportunities for patient re-evaluation of management strategies at our institution could be considered.

Temporarily Reversing Warfarin With Low-Dose 4-Factor Prothrombin Complex Concentrate in Left Ventricular Assist Device Patients Undergoing an Invasive Procedure

BACKGROUND

American Association for Thoracic Surgery and The International Society for Heart and Lung Transplantation (AATS/ISHLT) guidelines recommend warfarin in patients with continuous-flow left ventricular assist devices (LVADs) to reduce the risk of device thrombosis and systemic embolization. Left ventricular assist device patients often undergo elective and emergent procedures that require interrupted anticoagulation. Data and experience vary on the optimal strategy to rapidly reverse warfarin in LVAD patients when an emergent procedure is planned.

OBJECTIVE

The purpose of this study was to describe the use of 4-factor prothrombin complex concentrate (PCC4) for warfarin reversal in patients with LVADs undergoing elective and emergent procedures.

METHODS

This retrospective, single-center, cohort review describes the use of PCC4 in patients with LVADs who require warfarin reversal for elective or emergent procedures. The primary outcome was a composite incidence of pump thrombosis, venous thromboembolism, and ischemic stroke within 30 days of PCC4 administration.

RESULTS

In total, 14 patients received 17 administrations of PCC4. One patient received 3 administrations, and 1 other patient received 2 administrations during separate encounters. The median dose was 500 units or 6.6 units/kg (range = 4.2-14.1 units/kg). Of the PCC4 administrations, 82% (14/17) were for low bleed risk procedures and 76% (13/17) were for elective procedures. There were no cases of pump thrombosis, venous thromboembolism, or stroke within 30 days of the procedure.

CONCLUSIONS AND RELEVANCE

Low-dose PCC4 appears to be a safe and effective temporary reversal strategy for patients with LVADs undergoing low-bleed risk elective procedures.

Correction of Warfarin Coagulopathy for Non-bleeding Patients in the Outpatient Setting at an Ambulatory Care Organization: Application of Vitamin K Guidance

BACKGROUND

Warfarin is an effective anticoagulant but requires close International Normalized Ratio (INR) monitoring and may occasionally require correction of excessive anticoagulation. Current guidelines provide limited practical guidance on the administration of vitamin K for the management of supratherapeutic INR levels ≥ 5.0 in non-bleeding outpatients.

OBJECTIVES

Based on expert consensus and guidelines, the Atrius Health Anticoagulation Management Services (AMS) has developed internal guidance for oral vitamin K use in highly selected populations. This study will describe the internal guidance for oral vitamin K use and present associated results and clinical outcomes.

METHODS

Episodes with INR > 5.0 were included, with vitamin K considered for episodes with INR ≥ 6. Moreover, compelling indications and exclusions to select ideal patients for vitamin K intervention were also defined.

RESULTS

Overall, episodes were managed conservatively; of the 246 collected episodes of excessive anticoagulation, in 18 episodes (7%), patients received vitamin K, and in 228 (93%) episodes, patients did not receive vitamin K. The mean index INR was 6.0 (range 5.0 - 10.5, SD 1.07), with nearly 57% of episodes achieving INR correction and 15% of episodes developing INR overcorrection. High thrombotic risk patients, regardless of hemorrhagic risk, were less likely to receive vitamin K. Three episodes (1.2%) resulted in bleeding complications. No thrombotic complications occurred during the 30-day follow-up of the index INR value ≥ 5.0.

CONCLUSION

Our internal guidance is a novel, standardized approach that serves as a decision support tool for the management of warfarin-associated coagulopathy and vitamin K intervention using patient-specific characteristics and index INR values. This guidance may assist other anticoagulation management services with practical applications and require validation in a prospective clinical trial.

The effect of calf muscular vein thrombosis on the prognosis within one year postoperatively of geriatric hip fracture patients: a propensity score-matched analysis

INTRODUCTION

Calf muscular vein thrombosis (CMVT) is a type of distal deep vein thrombosis, which is common in geriatric hip fracture patients. However, studies focusing on whether the orthopedic operation has an impact on the prognosis of geriatric hip fracture patients with CMVT are very limited. Therefore, the aim of this study was to explore whether geriatric hip fractures with CMVT affect the mortality of patients within one year postoperatively. The difficulty of the operation, postoperative complications, the status of thrombosis, and function scores were also compared.

MATERIALS AND METHODS

Geriatric hip fracture patients who underwent surgery between January 2019 and January 2021 were included. Patients were divided into groups with and without CMVT by preoperative color Doppler ultrasound examination. Propensity score-matching (PSM) was performed in a ratio of 1:1 between the patient with and without CMVT groups. Baseline characteristics, laboratory results, perioperative indicators and prognosis of patients were collected retrospectively. Intraoperative and postoperative comparisons were conducted between patients with and without CMVT.

RESULTS

Two hundred and sixty geriatric hip fracture patients were included. Eighty-nine patients in each group were matched after PSM. There was no significant difference in mortality between the two groups at one-month, three-month, six-month, and one-year postoperatively. However, patients with CMVT had longer hospital stays, a higher incidence of postoperative complications, and a higher incidence of thrombosis progression than patients without CMVT in the follow-up.

CONCLUSION

No significant difference in mortality within one year postoperatively was observed in Chinese geriatric hip fracture patients with or without CMVT formation. Strategies such as close monitoring the status of thrombosis, individualized care, and strengthening rehabilitation are recommended to reduce the risk of complications and optimize patient outcomes in this patient population.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2300069411). Registered March 15, 2023, https://www.chictr.org.cn/showproj.html?proj=192079 .

WHO Disability Assessment Schedule 2.0: responsiveness in detecting long-term functional disability after surgery

BACKGROUND

The WHO Disability Assessment Schedule (WHODAS) 2.0 is widely used for detecting postoperative functional disability. Its responsiveness for detecting disability has been evaluated at 1 year after surgery, with no long-term evaluation. The aim of this study was to examine the responsiveness of the WHO Disability Assessment Schedule in detecting functional disability at 5 years after surgery.

METHODS

This study was a secondary analysis of a prospective observational study. Patients were enrolled who were aged 55 years or older and underwent elective non-cardiac surgery under general anaesthesia. They were asked to complete the 12-item WHO Disability Assessment Schedule and the Medical Outcome Study Short Form questionnaires before surgery and at 5 years after surgery. The correlation between changes in WHO Disability Assessment Schedule score and Medical Outcome Study Short Form physical score (change in physical component score) was evaluated using the Spearman rank correlation coefficient (ρ). The standardized response means were also calculated for typical subgroups for which functional disability was predicted to improve or decline and compared with the overall standardized response mean.

RESULTS

In the analysis, 2596 patients were included. A moderate correlation (ρ = -0.47) existed between changes in WHO Disability Assessment Schedule and physical Medical Outcome Study Short Form scores. The overall standardized response mean was 0.17. The standardized response means for the patients with functional disability predicted to improve ranged from -0.45 to -0.67, whereas those for patients predicted to decline ranged from 0.17 to 0.56. These findings indicated high responsiveness.

CONCLUSION

The WHO Disability Assessment Schedule 2.0 has a high responsiveness at 5 years after surgery. It can be used to detect functional disability at 5 years after surgery.

Direct-Acting Oral Anticoagulant Dabigatran as a Bridging Therapy while Optimizing Warfarin Dosage for Cardioembolic Stroke

INTRODUCTION

Parenteral heparin is widely used as bridging therapy while optimizing oral anticoagulation (OAC). Newer direct-acting OACs (DOACs) attain therapeutic effect very quickly. We report the use of dabigatran as bridging therapy during warfarin optimization for cardioembolic stroke in two patients who opted to receive warfarin for long-term anticoagulation for secondary stroke prevention.

CASE PRESENTATIONS

Patient A was a 60-year-old man with hypertension, hyperlipidaemia, and gout who was admitted with a sudden onset of left-sided weakness. Clinically, he was alert but had right gaze preference and left-sided hemiplegia. The clinical diagnosis was of a right cortical stroke. He underwent intravenous tPA augmented with sonothrombolysis - the National Institute of Health Stroke Scale (NIHSS) score fell from 7 to 0. Repeat brain scan showed infarcts in the right frontal and parietal lobes. He was found to have atrial fibrillation (AF) and advised anticoagulation. He opted for warfarin with dabigatran bridging which was started on day 2 of his hospital admission. His International Normalized Ratio (INR) exceeded 2 by day 6 of anticoagulation, at which time the bridging dabigatran was stopped, fixed-dose warfarin was continued, and he was discharged well. On subsequent reviews in the clinic, his INR was in the therapeutic range of 2.0-3.0. He had no bleeding or recurrent ischaemic events during follow-up. Patient B was a 78-year-old man with a hypertension, hyperlipidaemia, and diabetes mellitus. He was admitted after he developed difficulty talking and mild right-sided weakness. Clinically, he was alert but had expressive aphasia and mild right-sided upper limb weakness (NIHSS 6). The clinical diagnosis was of a left cortical stroke. The brain scan showed a left posterior frontal and parietal infarct. He was out of the time window for recanalization therapy and was treated conservatively. He was found to have AF and advised anticoagulation. He opted for warfarin with dabigatran bridging which was started on day 1 of his hospital admission. His INR was almost 2 by day 5 of anticoagulation, at which time the bridging dabigatran was stopped and fixed-dose warfarin continued. He declined daily blood taking - his INR 4 days later was in the therapeutic range of 2.0-3.0. He had no bleeding or recurrent ischaemic events. He underwent rehabilitation uneventfully and was discharged well.

CONCLUSIONS

The use of DOACs such as dabigatran as bridging therapy during optimization of OAC is feasible. Compared to heparin as bridging therapy, DOAC has the advantage of oral administration, lower cost, and possibly lower bleeding risks. This novel practice may be applicable in thrombosis in arterial and venous circulations, e.g., ischaemic stroke, deep venous thrombosis, pulmonary embolism.

Intraoperative Systolic Blood Pressure as a Significant Predictor of Postoperative Hematoma Following Facelift: Single-Surgeon Experience of 118 Consecutive Facelifts

BACKGROUND

Although there exists ample evidence on the impact of perioperative blood pressure on hematoma incidence following facelift, the association of elevated or labile intraoperative blood pressure with postoperative hematoma remains to be explored.

OBJECTIVES

The authors evaluated the association of elevated or labile intraoperative systolic blood pressure (SBP) with postoperative hematoma, based on the senior author's single surgeon experience of 118 consecutive facelifts.

METHODS

A multivariate logistic regression was conducted using complete demographic, procedure-related, blood pressure-related, and outcomes-related data, with the outcome of interest representing postoperative hematoma. One-way analysis of variance and linear regression analyses were performed to assess for significant associations between a preoperative history of hypertension and a tendency to demonstrate elevated or labile intraoperative SBP. A Fisher's exact test was subsequently applied to assess for specific intraoperative SBP measurement cutoffs significantly associated with postoperative hematoma, including maximum recorded intraoperative SBP, and the specific degree of intraoperative SBP fluctuation.

RESULTS

Multivariate logistic regression demonstrated no statistically significant patient- or procedure-related demographic predictors of postoperative hematoma. With aggressive treatment of preoperative hypertension, high preoperative SBP was not found to be a significant predictor of postoperative hematoma following facelift, although this approached statistical significance (P = .05). In contrast, labile intraoperative SBP (maximum recorded intraoperative SBP minus minimum recorded intraoperative SBP; P = .026) and high immediate postoperative SBP (P = .002) were both independent and statistically significant predictors of postoperative hematoma. Patients with a preoperative history of hypertension, and more specifically those with elevated SBP measurements in the preoperative clinic, were more likely to demonstrate labile (P = .007) or elevated (P = .005) intraoperative SBP during facelift surgery. Specifically, maximum recorded intraoperative SBP ≥155 mmHg (P = .045) and maximum intraoperative SBP fluctuations ≥80 mmHg (P = .036) were found to be significantly associated with hematoma.

CONCLUSIONS

A multimodal approach is necessary to control perioperative systolic blood pressure within the strict <120 mmHg target demonstrated to significantly decrease hematoma incidence. The senior author's preference is for intraoperative SBP to remain within a strict 90 to 100 mmHg range. In contrast to hypertension that is aggressively treated and successfully controlled, hypertension that is difficult to control intraoperatively may be a predictor of systolic blood pressure that is difficult to control postoperatively, and therefore a significant risk factor for postoperative hematoma following facelift.

LEVEL OF EVIDENCE: 4 (THERAPEUTIC)

The rate of postoperative hematoma following risk-adapted cessation of oral anticoagulation in patients undergoing endoscopic endonasal surgery for pituitary adenomas

BACKGROUND

This study describes the management of patients on oral anticoagulation (OAC) undergoing endoscopic endonasal transsphenoidal surgery (EETS) and analyzes the risk of postoperative hematoma and epistaxis following treatment of pituitary adenoma (PA).

METHODS

Patients with OAC prior to EETS for PA were analyzed in a single center retrospective case series of consecutive patients with PA, who were treated between December 2008 and July 2022. Patient data (age, sex, clinical, endocrinology, tumor histology) were entered into a SPSS® database. The rate of postoperative hemorrhage (intracranial and epistaxis) and other perioperative complications were assessed.

RESULTS

Of 305 patients, 20 patients were on OAC prior to EETS for PA. Indications included non-valvular atrial fibrillation (AF) in 10 patients and previous venous thromboembolic event (VTE) in 8 patients, in 2 patients had overlapping indications. Twelve patients on direct oral anticoagulants (DOAC) paused medication 1-3 days (43.6 ± 23.6 h) before surgery, while phenprocoumon was paused 234 ± 123.55 h (min 6, max 22 days) before surgery. Baseline characteristics such as age, sex, tumor growth direction, tumor volume, and largest diameter showed no significant differences. No significant increase in postoperative hemorrhage was observed in patients with OAC compared to those without. One patient on apixaban paused 48 h before surgery experienced postoperative epistaxis. Among patients without OAC, one experienced intracranial hemorrhage and seven experienced epistaxis.

CONCLUSION

Patients with OAC prior to EETS for PA have no increased risk for postoperative hematoma when OAC is paused based on individual risk assessment and recent general recommendations.

Early thrombus formation is required for eccentric and heterogeneous neointimal hyperplasia under disturbed flow

BACKGROUND

Anticoagulation and antiplatelet therapy effectively inhibit neointimal hyperplasia (NIH) in both arterial and venous systems but not in arteriovenous fistulae (AVF). The main site of AVF failure is the juxta-anastomotic area that is characterized by disturbed flow compared with laminar flow in the arterial inflow and the venous outflow.

OBJECTIVES

We hypothesized that early thrombus formation is required for eccentric and heterogeneous NIH in the presence of disturbed flow.

METHODS

Needle puncture and sutured AVF were created in C57BL/6 mice, in PF4-Cre × mT/mG reporter mice, and in Wistar rats. Human AVF samples were second-stage basilic vein transpositions. The tissues were examined by histology, immunofluorescence, immunohistochemistry, and en face staining.

RESULTS

In the presence of disturbed flow, both mouse and human AVF showed eccentric and heterogeneous NIH. Maladapted vein wall was characterized by eccentric and heterogeneous neointima that was composed of a different abundance of thrombus and smooth muscle cells. PF4-cre × mT/mG reporter mice AVF showed that green fluorescent protein-labeled platelets deposit on the wall directly facing the fistula exit with endothelial cell loss and continue to accumulate in the presence of disturbed flow. Neither disturbed flow with limited endothelial cell loss nor nondisturbed flow induced heterogeneous neointima in different animal models.

CONCLUSION

Early thrombus contributes to late heterogeneous NIH in the presence of disturbed flow. Disturbed flow, large area of endothelial cell loss, and thrombus formation are critical to form eccentric and heterogeneous NIH. Categorization of adapted or maladapted walls may be helpful for therapy targeting heterogeneous NIH.

Preoperative medication management turnkey order set for nonemergent adult cardiac surgery

Objective

The management of preoperative medications is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Numerous guidelines and expert consensus documents have been published to provide guidance in preoperative medication management. Our objective is to integrate these documents into an evidence-based order set that will facilitate standardized implementation of best practices for preoperative medication management for nonemergent adult cardiac surgery.

Methods

Subject matter experts were consulted to translate existing guidelines and peer reviewed literature into a sample turnkey order set for the preoperative management of patients' medications. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type.

Results

Holding antiplatelet and anticoagulant medications before nonemergent cardiac surgical procedures may reduce the risk of bleeding. Sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 agonists should also be discontinued to prevent acidosis and aspiration, respectively. Specific guidance for frequently used medications are complied within the manuscript, less frequently used medications are listed seperately.

Conclusions

Despite strong recommendations from major guidelines and consensus manuscripts, variation exists in preoperative medication orders, with limited availability of succinct implementation tools. This turnkey order set may facilitate standardized comprehensive preoperative medication management before nonemergent cardiac surgery.

Multidisciplinary consensus-based statement on the current role of middle meningeal artery embolization (MMAE) in chronic SubDural hematoma (cSDH)

Introduction

Middle Meningeal Artery Embolization (MMAE) in patients with chronic SubDural Hematoma (cSDH) is a novel treatment approach, albeit the specific role of MMAE in the treatment of cSDH is not yet defined.

Research question

The aim of this work is to provide a consensus-based statement from a multidisciplinary panel on the current role of MMAE in patients with cSDH.

Materials and methods

A literature search was performed using the keywords MMAE and cSDH. Based on the available published data, the panel was asked if a consensus could be reached on the role of MMAE in both de novo as well as in recurrent cSDH.

Results

The panel reached a consensus on the current role of MMAE in both de novo- and recurrent cSDH, as well as in patients on antithrombotics and those with coagulopathy. MMAE should be considered in the following scenarios:1)As "stand-alone" treatment in de novo cSDH requiring intervention but where surgery is prevented due to either coagulopathy or in patients on antithrombotics in whom the risk of suspension is considered unacceptably high,2)as "stand-alone" treatment in recurrent cSDH requiring intervention but where surgery is prevented due to either coagulopathy or in those on antithrombotics in whom the risk of suspension is considered unacceptably high and3)as "adjunct to surgery" in all recurrent cSDH.

Discussion and conclusion

This statement is to be considered an expert consensus opinion of delegates representing key international medical societies of specialists involved in the care of cSDH patients.

Perioperative direct oral anticoagulant management during cardiac implantable electronic device surgery: an updated systematic review and meta-analysis

BACKGROUND

Patients undergoing cardiovascular implantable electronic device (CIED) implantation are often on direct oral anticoagulation (DOAC). However, the evidence on whether to continue or temporarily discontinue DOAC therapy during the perioperative period in these patients is unclear.

METHODS

We conducted a comprehensive literature review using PubMed, Embase, and Cochrane databases through July 2024. We included studies comparing uninterrupted versus interrupted perioperative DOAC therapy in patients undergoing CIED procedure- primary implants, pulse generator replacement, and device upgrades. Primary outcomes were clinically significant device-pocket hematoma and thromboembolic events. Secondary outcomes included any device-pocket hematoma, all-cause mortality, major bleeding, and any bleeding.

RESULTS

A total of 1,607 patients from 8 studies were included. The mean age was 73.2 years, with atrial fibrillation as the indication for DOAC therapy in most patients. The mean CHA2DS2-VASc was 3.4. Among the included studies, 2 were randomized control trials (RCTs), while the others were observational cohort studies, including one that was propensity score matched. Our meta-analysis found both strategies to be similar in terms of clinically significant pocket hematoma (RR 1.70; 95%CI 0.84-3.45; p = 0.14; I2 = 0%), thromboembolic complications (RR 0.35; 95%CI 0.04-3.32; p = 0.36; I2 = 19%), any pocket hematoma, all-cause mortality and any bleeding with a higher risk of major bleeding with uninterrupted anticoagulation.

CONCLUSION

This meta-analysis shows that uninterrupted DOAC therapy is comparable to interrupted therapy for CIED procedures, with a potential increase in major bleeding risk but low overall complication rates. Further research is needed to confirm the best approach of periprocedural anticoagulation in these patients.

Adherence to periprocedural antithrombotic treatment recommendations and its prognostic impact in patients with high ischemic and hemorrhagic risk

INTRODUCTION AND OBJECTIVES

To analyze the clinical impact of the inappropriate use of antithrombotic treatment in patients with high ischemic or hemorrhagic risk during the periprocedural/perisurgical period in Spain.

METHODS

Prospective multicenter observational registry of patients receiving antiplatelet and/or anticoagulant therapy who required an intervention. The incidence of 30-day events was compared based on the peri-intervention management of antithrombotic treatment and the patients' risk classification (high vs. moderate-to-low risk). The primary endpoint was a composite of death, cardiovascular ischemic events, or bleeding events classified as BARC 2 or higher.

RESULTS

A total of 1152 patients were analyzed. Of these, 1.9% had both high ischemic and hemorrhagic risks (A);10.8% had high ischemic risk and low-to-moderate hemorrhagic risk (B); 12% had high hemorrhagic risk and low-to-moderate ischemic risk (C); and 75.3% had both low-to-moderate risks (D). The prevalence of inappropriate treatment was higher in the subgroup with high hemorrhagic risk and low-to-moderate ischemic risk (C) (62.6% vs 40.9% in subgroup A; P<.05; 40.3% in subgroup B; P<.001; and 39.8% in subgroup D; P<.05). The incidence of the composite endpoint was higher in the subgroups with high ischemic and hemorrhagic risks (22.7%) and high ischemic and low-to-moderate hemorrhagic risks (20.9%), compared with 3.6% in subgroup C (P<.05) and 5.7% in subgroup D (P<.001). Among patients with inappropriate treatment, the incidence of the composite endpoint was significantly higher in subgroups with high ischemic and hemorrhagic risks (44.4% vs 7.7%; P=.043) and high ischemic and low-to-moderate hemorrhagic risks (30% vs 14.8%; P=.042).

CONCLUSIONS

The prevalence of inappropriate periprocedural/perisurgical treatment was higher in patients with high hemorrhagic risk and low-to-moderate ischemic risk. The incidence of events was higher in patients with high ischemic risk, with inadequate antithrombotic management being associated with a higher event rate in these groups.

Use of Prophylactic or Therapeutic Anticoagulation in Critically Ill Patients With Pre-existing Atrial Fibrillation

Purpose: The optimal anticoagulation regimen for atrial fibrillation (AF) in critically ill patients is challenging as these patients may be at an increased risk for bleeding and clotting despite an absence or presence of anticoagulation. The purpose of this study was to compare bleeding and thrombotic rates in critically-ill adults with pre-existing AF receiving therapeutic anticoagulation versus chemical or mechanical venous thromboembolism prophylaxis. Methods: A retrospective, observational study was conducted. The primary outcome identified rate of International Society of Thrombosis and Hemostasis bleeding, and secondarily assessed all venous or arterial thromboembolic events. To determine risk-factors associated with bleeding and to account for differences in baseline characteristics, a multivariable logistic regression model was used. Results: A total of 199 patients were included, 100 receiving therapeutic anticoagulation and 99 receiving venous thromboembolism prophylaxis. Patients receiving therapeutic anticoagulation compared to chemical or mechanical prophylaxis had a median (IQR) CHA2DS2VASc score of 4 (3-5) versus 4 (2-5) (P = .5499) and HAS-BLED score of 3 (3-4) versus 3 (2-4) (P = .0013); respectively. There was almost a threefold adjusted increased risk of bleeding in patients receiving therapeutic anticoagulation compared to venous thromboembolism prophylaxis (adjusted odds ratio [aOR] 2.7 [95% CI 1.1-9.9]; P = .0349). One stroke occurred in a patient receiving therapeutic anticoagulation, and none occurred in patients in the prophylaxis group (P = 1.000). Conclusion: Use of therapeutic anticoagulation in critically ill patients with pre-existing AF may increase bleed rates without protecting against stroke development.

The pharmacist's role in optimizing medication management before, during, and after minimally invasive and bariatric surgery

PURPOSE

Minimally invasive surgery (MIS) with integrated enhanced recovery pathways (ERPs) helps reduce length of stay and improve surgical outcomes. As these procedures have become more prevalent over time, pharmacists are in key positions to manage medications in the perioperative space to help optimize transitions of care and reduce safety events. Here we identify several clinical areas across phases of care for these procedures in which the knowledge and guidance of pharmacists, as members of the interprofessional team, are paramount.

SUMMARY

Perioperative pharmacy expertise is often required for MIS procedures in the areas of acid suppression, antithrombotic management, blood glucose control, drug formulation, immunosuppressant optimization, pain mitigation, and postoperative nausea and vomiting prevention and treatment. For each MIS procedure, pharmacists should identify and consider diet and anatomical changes as well as patient- and surgery-specific risk factors. Pharmacists can then utilize their knowledge of the pharmacokinetics and pharmacodynamics of individual medications along with evidence-based medicine to recommend selection of appropriate agents.

CONCLUSION

Pharmacist contributions to perioperative medication management for MIS procedures can improve care as surgical patients navigate transitions through the perioperative setting. Pharmacists can further incorporate medication expertise through development and implementation of institutional MIS protocols within the context of ERPs. As such, any pharmacist should feel empowered to aid in the care of surgical patients.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Impact of elevated direct factor Xa inhibitor plasma levels on perioperative blood loss in patients undergoing urgent surgery

INTRODUCTION

Data on the perioperative bleeding risk associated with elevated plasma levels of direct factor Xa inhibitors (FXa inhibitors) are limited. This study examines perioperative red blood cell (RBC) loss in patients undergoing urgent surgery with a residual FXa inhibitor level exceeding 100 mcg/L and without preoperative FXa inhibitor reversal.

METHODS

This retrospective analysis includes data from 32 patients who underwent urgent noncardiac surgery between 2018 and 2022. This study aims to analyze perioperative RBC loss in patients undergoing urgent surgery with a residual FXa inhibitor level exceeding 100 mcg/L and without preoperative FXa inhibitor antidote-based reversal or unspecific treatment with 4-factor prothrombin complex concentrate (PCC). All patients were managed using a watch-and-wait strategy.

RESULTS

The last determination of FXa inhibitor plasma concentration prior to surgery showed a median of 245 mcg/L (IQR 144-345), with a median time interval of 3.8 h (IQR 2.4-7.2) before incision. Median RBC loss during surgery was 49 mL (IQR 0-253), 189 mL (IQR 104-217) until POD1 and 254 mL (IQR 58-265) until POD3. Only one patient required intraoperative treatment with 4-factor-PCC and none required reversal with andexanet alfa. Linear regression models found no significant influence of FXa inhibitor plasma levels on intraoperative RBC loss. Rivaroxaban was associated with higher RBC loss until postoperative Day 1 compared with apixaban. No thromboembolic events were observed.

CONCLUSION

Despite markedly elevated plasma concentrations of residual direct FXa inhibitors, perioperative RBC loss was limited in patients undergoing urgent noncardiac surgery. The intraoperative watch-and-wait strategy with selective intraoperative FXa inhibitor reversal or treatment only when required appears to be an appropriate approach.

International normalized ratio measurement during perioperative anticoagulation bridging with low-molecular-weight heparin in patients undergoing heart valve replacement surgery

Background

Surgical procedures in anticoagulated patients require specific attention due to increased bleeding risk. Preoperative anticoagulation interruption in high-risk patients is often necessary. Bridging anticoagulation with low-molecular-weight heparin (LMWH) minimizes thromboembolic risk, but its effect on international normalized ratio (INR) measurement is not well established, necessitating careful monitoring and individual assessment.

Objectives

To investigate the effect of heparin bridging on INR measurements in anticoagulated patients on vitamin K antagonist (VKA) and in in vitro spiking experiments.

Methods

Thirty-eight anticoagulated patients on VKA undergoing valve replacement surgery were studied using 2 plasma-based INR assays and 1 whole blood point-of-care INR method at multiple time points after postoperatively resuming VKA. In addition, INR levels in pooled plasma of both normal and VKA-treated individuals were compared, with 7 spiked concentrations of LMWH or unfractionated heparin (UFH) in 4 INR assays.

Results

In LMWH-bridged anticoagulated patients, the INR results obtained with HemosIL RecombiPlasTin and point-of-care Coaguchek were significantly higher than those obtained with STA Hepato Prest within 3 days after restart of VKA. After spiking LMWH or UFH in various concentrations into pooled plasma, only the STA Hepato Prest assay showed no interference in INR measurement within the therapeutic range (1.0-2.0 international units/mL) in both VKA and normal plasma. All other assays showed substantial interference, with the Thromborel S assay being the most heparin-sensitive assay.

Conclusion

Differences between INR methods are seen within 72 hours after restarting VKA in postoperative patients who receive LMWH bridging. In vitro experiments using LMWH and UFH show the interference of heparin in multiple INR methods, even with concentrations below the suppliers' stated heparin interference limits.