Factor V Leiden and perioperative risk

Complications of Factor V Leiden in Adults Undergoing Noncardiac Surgical Procedures: A Systematic Review

Factor V Leiden is the commonest hereditary prothrombotic allele, affecting 1% to 5% of the world's population. The objective of this study was to characterize the perioperative and postoperative outcomes of patients with Factor V Leiden compared to patients without a diagnosis of hereditary thrombophilia. This was a focused systematic review of studies including adult (>18 years) patients with Factor V Leiden (heterozygous or homozygous) undergoing noncardiac surgery. Included studies were either randomized controlled trials or observational. The primary clinical outcomes of interest were thromboembolic events occurring from the perioperative period up to 1 year postoperatively, defined as deep venous thrombosis, pulmonary embolism, or other clinically significant thrombosis occurring during or after a surgical procedure. Secondary outcomes included cerebrovascular events, cardiac events, death, transplant-related outcomes, and surgery-specific morbidity. Pediatric and obstetrical patients were excluded, as were case reports and case series. Databases searched included MEDLINE and EMBASE from inception until August 2021. Study bias was assessed through the CLARITY (Collaboration of McMaster University researchers) Risk of Bias tools, and heterogeneity through analysis of study design and end points, as well as the I 2 statistic with its confidence interval and the Q statistic. A total of 5275 potentially relevant studies were identified, with 115 having full text assessed for eligibility and 32 included in the systematic review. On the whole, the literature suggests that patients with Factor V Leiden have an increased risk of perioperative and postoperative thromboembolic events compared to patients without the diagnosis. Increased risk was also seen in relation to surgery-specific morbidity and transplant-related outcomes, particularly arterial thrombotic events. The literature did not support an increased risk for mortality, cerebrovascular, or cardiac complications. Limitations of the data include predisposition toward bias due in many study designs and small sample sizes across the majority of published studies. Variable outcome definitions and durations of patient follow-up across different surgical procedures resulted in high study heterogeneity precluding the effective use of meta-analysis. Factor V Leiden status may confer additional risk for surgery-related adverse outcomes. Large, adequately powered studies are required to accurately estimate the degree of this risk by zygosity.

Laboratory Diagnosis of Activated Protein C Resistance and Factor V Leiden

The factor V Leiden (FVL) polymorphism is known as the most common inherited risk factor for venous thrombosis. In turn, FVL is the leading cause of an activated protein C resistance (APCR) phenotype, in which the addition of exogenous activated protein C to plasma does not result in the expected anticoagulant effect. In the routine laboratory approach to the formal diagnosis of FVL, an initial positive screening plasma-based method for APCR is often performed, and only if needed, this is followed by a confirmatory DNA-based assay for FVL. Multiple methods with accepted sensitivity and specificity for determining an APCR/FVL phenotype are commonly categorized into two separate groups: (1) screening plasma-based assays, including qualitative functional clot-based assays, for APCR, and (2) confirmatory DNA-based molecular assays, entailing several tests and platforms, including polymerase chain reaction-based and non-PCR-based techniques, for FVL. This review will describe the methodological aspects of each laboratory test and prepare suggestions on the indication of APCR and FVL testing and method selection.

The utility of thrombophilia and hematologic screening in live liver donation

BACKGROUND

Most centers perform some degree of hematologic screening, including thrombophilia testing, on prospective live liver donors. The nature and extent of such screens are not standardized, and there is limited evidence regarding hematologic risk stratification.

METHODS AND RESULTS

We present an experience of hematologic screening among prospective liver donors. Five-hundred-eightyfour patients were screened for liver donation between 1/2013 and 1/2020, of whom 156 (27%) proceeded to donor hepatectomy. Thirty-three of 428 (8%) declined patients were excluded for hematologic indications. Hematologic indications were the 2nd most frequent medical indications for exclusion (trailing only hepatologic indications). The most common reason for hematologic exclusion was concern regarding thrombophilia. Nevertheless, 21 patients with evidence of possible thrombophilia proceeded to donor hepatectomy, and none incurred hematologic complications. Similarly, seven patients with screening findings concerning for increased bleeding risk (most often thrombocytopenia) underwent donor hepatectomy without hematologic complication. Three of 156 (2%) of patients who underwent donor hepatectomy incurred a hematologic complication (all thrombotic, none fatal). None of these patients had any evident hematologic risk factor on screening.

CONCLUSION

This study underscores the difficulty of hematologic risk stratification among prospective living donors, however, suggests that some patients with relatively mild risk factors may be safe for donation.

Recurrent thrombosis after carotid endarterectomy secondary to activated protein C resistance and essential thrombocytosis: A case report

RATIONALE

Thrombosis is a major cause of morbidity in the perioperative period. Although many risk factors are known, activated protein C resistance is a prominent risk for thrombosis. Activated protein C resistance frequently occurs with recurrent thromboembolism.

PATIENT CONCERNS

A 59-year-old Korean woman patient with hypertension was admitted due to dysarthria and left side motor weakness.

DIAGNOSIS AND INTERVENTIONS

Magnetic resonance imaging showed subacute cerebral infarction with right frontoparietal lobe and stenosis at the right internal carotid artery. She underwent right carotid endarterectomy under general anesthesia. However, recurrent thrombosis on postoperative day 1 was noted at patient's right carotid artery, which prompted emergency surgery. Additional preoperative laboratory review revealed findings for activated protein C resistance, low protein S activity, antinuclear antibody (>1:160), anti-cardiolipin IgM antibody (16.6), and thrombocytosis, Janus kinase and factor V Leiden mutations. At the intensive care unit, heparin was continually infused until postoperative day 12 and was then switched to warfarin.

OUTCOMES

Patient was discharged at postoperative day 21 without any event. Patient had no signs of recurrence within the 3-year follow-up period, and she is still on oral warfarin and clopidogrel.

LESSONS

Screening test for hypercoagulability can be used to identify patients at higher risk of postoperative complications. If hypercoagulability state is confirmed by laboratory testing, a suitable anticoagulant treatment plan should be made within the perioperative period.

Periocular molluscum contagiosum: six different clinical presentations

PURPOSE

To describe the different clinical presentations of periocular molluscum contagiosum (MC) lesions and their epidemiological, clinical and histopathological features.

METHODS

Medical records and histopathological sections of all cases of periocular MC treated at the oculoplastic clinic of the Goldschleger Eye Institute, Sheba Medical Center, Israel, between 1995 and 2016 were retrospectively reviewed. The following data were extracted: gender, age at the time of MC diagnosis, immune competency, location of the periocular lesions, number of lesions, dimensions of the lesions, clinical presentation, histopathological features, suspected clinical diagnosis before histopathological diagnosis and treatment.

RESULTS

The series was composed of 41 patients (19 males, 22 females) whose mean age at presentation was 20.41  ±  21.10 years (range 1-71 years). Only one patient was immunosuppressed. The cases were classified into six proposed clinical presentations: 'umbilicated nodular', 'big/giant', 'conglomerated', 'erythematous', 'inflamed' and 'pedunculated'.

CONCLUSION

This is the first time that different clinical types of MC lesions are labelled. The current evidence also indicates that MC lesions should be suspected not only in children and in immunosuppressed adult patients but also in immunocompetent patients of all ages.

Perioperative Management of Factor V Leiden and Pancreatic Adenocarcinoma

Background: Perioperative management of a patient with factor V Leiden has been infrequently reported with most studies focused in the orthopedic literature.

Case Presentation: We report a case of a 74-year-old woman who underwent a pylorus-preserving pancreaticoduodenectomy without immediate perioperative embolic or thrombotic phenomena and her management throughout her hospital course.

Conclusion: To the best of our knowledge, this is the first known report regarding factor V Leiden and surgical management of pancreatic ductal adenocarcinoma.

Disseminated intravascular and intracardiac thrombosis after cardiopulmonary bypass

Massive intracardiac and intravascular thrombosis is a rare complication following cardiopulmonary bypass (CPB). Most of the cases of the disseminated thrombosis have been reported in patients undergoing complex cardiac surgeries and those receiving antifibrinolytic agents during CPB. We report the occurrence of disseminated intravascular and intracardiac thrombosis after CPB in a patient undergoing mitral valve replacement in which no antifibrinolytic agent was used. The possible pathophysiology and management of the patient is discussed.

The hypercoagulable states in anaesthesia and critical care

Hypercoagulable disorders are now diagnosed more frequently than before. These patients are, usually, managed with multiple anticoagulant and antiplatelet medications. Left unmonitored and unevaluated, there can be disastrous haemorrhagic or thrombotic complications. Appropriate perioperative and anaesthetic management of these patients will invite an aetiological diagnosis, severity analysis and the on-going treatment review. Different assays, thromboelastography and molecular cytogenetics have helped to diagnose these conditions precisely and thus guide the long-term management. Besides this, there are varieties of clinical conditions that will predispose to the hypercoagulability. These need to be defined and classified in order to offer a suitable therapeutic option. Pregnancy is one such important condition and can have more than one responsible factor favouring hypercoagulability. With such diverse kinds of disorders, it would be essential to note the anaesthetic implications, to avoid adverse perioperative outcomes. Available evidence based guidelines will help to make the therapeutic approach more precise. Selection of the appropriate technique of anaesthesia, offering the appropriate anticoagulation bridging as necessary and defining an appropriate interval and time for the intervention will help to minimise the complications.

Perioperative genomic profiles using structure-specific oligonucleotide probes

OBJECTIVES

Many complications in the perioperative interval are associated with genetic susceptibilities that may be unknown in advance of surgery and anesthesia, including drug toxicity and inefficacy, thrombosis, prolonged neuromuscular blockade, organ failure and sepsis. The aims of this study were to design and validate the first genetic testing platform and panel designed for use in perioperative care, to establish allele frequencies in a target population, and to determine the number of mutant alleles per patient undergoing surgery. DESIGN/SETTING/PARTICIPANTS AND METHODS: One hundred fifty patients at Marshfield Clinic, Marshfield, Wisconsin, 100 patients at the Medical College of Wisconsin Zablocki Veteran's Administration Medical Center, Milwaukee, Wisconsin, and 200 patients at the University of Wisconsin Hospitals and Clinics, Madison, Wisconsin undergoing surgery and anesthesia were tested for 48 polymorphisms in 22 genes including ABC, BChE, ACE, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5, beta2AR, TPMT, F2, F5, F7, MTHFR, TNFalpha, TNFbeta, CCR5, ApoE, HBB, MYH7, ABO and Gender (PRKY, PFKFB1). Using structure-specific cleavage of oligonucleotide probes (Invader, Third Wave Technologies, Inc., Madison, WI), 96-well plates were configured so that each well contained reagents for detection of both the wild type and mutant alleles at each locus.

RESULTS

There were 21,600 genotypes confirmed in duplicate. After withdrawal of polymorphisms in non-pathogenic genes (i.e., the ABO blood group and gender-specific alleles), 376 of 450 patients were found to be homozygous for mutant alleles at one or more loci. Modes of two mutant homozygous loci and 10 mutant alleles in aggregate (i.e., the sum of homozygous and heterozygous mutant polymorphisms) were observed per patient.

CONCLUSIONS

Significant genetic heterogeneity that may not be accounted for by taking a family medical history, or by obtaining routine laboratory test results, is present in most patients presenting for surgery and may be detected using a newly developed genotyping platform.

Frequency, predictors, and neurologic outcomes of vaso-occlusive strokes associated with cardiac surgery in children

OBJECTIVE

Our aim was to define the frequency, predictors, and outcomes of stroke associated with cardiac surgery in children with congenital heart disease.

METHODS

We performed a case-control study of children (term birth to 18 years) with congenital heart disease who underwent cardiac surgery at the Hospital for Sick Children between January 1, 1992, and March 1, 2001. Case subjects experienced stroke within 72 hours after cardiac surgery, and control subjects (2 for each case subjects) had cardiac surgery and no stroke. The frequency of arterial ischemic stroke/cerebral sinovenous thrombosis was calculated among children who underwent cardiac surgery during the study period. Predictors for stroke, including age, gender, simple versus complex procedure, reoperation, bypass duration, circulatory arrest, postoperative hematocrit level, and intraoperative activated clotting time, were tested. The presence of clinical and radiologically defined stroke was the main outcome. Neurologic outcomes were assessed in case subjects with the Pediatric Stroke Outcome Measure.

RESULTS

During the study period, 30 children with stroke (28 with arterial ischemic stroke and 2 with cerebral sinovenous thrombosis) were identified among 5526 children undergoing cardiac surgery. This yielded a risk for arterial ischemic stroke/cerebral sinovenous thrombosis of 5.4 strokes per 1000 children undergoing a cardiac operation. Univariate analysis revealed that older age at the time of the procedure, longer duration of cardiopulmonary bypass, number of days in the hospital postoperatively, and reoperation were associated with stroke. In multivariate analyses, only reoperation was associated with stroke.

CONCLUSIONS

The frequency of vaso-occlusive stroke in children with congenital heart disease undergoing cardiac surgery was 5.4 cases per 1000 children. Age, duration of bypass, and reoperation may be associated with stroke risk.

Mini-gastric bypass in a patient homozygous for Factor V Leiden

A 42-year-old morbidly obese female, homozygous for Factor V Leiden, underwent mini-gastric bypass without complications. The recommendations for prophylaxis in this high-risk population are unclear and most likely involve a combination of pharmacologic and non-pharmacologic measures.

Genetics of coagulation: considerations for cardiac surgery

Genetic variants in the coagulation system have been known since antiquity. Today, because of modern improvements in diagnosis and medical management, the clinician is likely to encounter a spectrum of coagulation factor deficiencies and identified polymorphic variants in the surgical population. Because perioperative hemorrhagic and thrombotic complications are potentially serious, it is important to understand the role that these defects and variants may play in predicting risk and optimizing patient management. The implications of coagulation genetics on the perioperative management of the cardiac surgery patient are reviewed.

New Paradigms in Cardiovascular Medicine

Considerable progress has been made in understanding the pathophysiology of perioperative stress responses and their impact on the cardiovascular system; however, researchers are just beginning to unravel genetic and molecular determinants that predispose to increased risk for postoperative cardiovascular adverse events. A new field, coined perioperative genomics, aims to apply functional genomic approaches to uncover the biological reasons why similar patients can have dramatically different clinical outcomes after surgery. For the perioperative physician, such findings may soon translate into prospective risk assessment incorporating genomic profiling of markers important in inflammatory, thrombotic, vascular, and neurologic responses to perioperative stress, with implications ranging from individualized additional pre-operative testing and physiological optimization, to perioperative decision-making, choice of monitoring strategies, and critical care resource utilization. We review current knowledge regarding genomic technologies in perioperative cardiovascular disease characterization and outcome prediction, as well as discuss future trends/challenges for translating integrated "omic" information into daily clinical management of the surgical patient.

Factor V Leiden and its effect on children with cardiac pathology

Factor V Leiden thrombophilia, formed by a genetic mutation, slows the body's anticoagulation response to clot formation. First described in 1994, factor V Leiden mutation has been identified as a contributing risk factor for venous thromboembolism. Although venous thromboembolism is considered rare in the pediatric population, Factor V Leiden has implications for certain at-risk pediatric patients.