A COVID-19 Patient with Simultaneous Renal Infarct, Splenic Infarct and Aortic Thrombosis during the Severe Disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with a high incidence of arterial and venous thrombotic complications. However, thromboembolic events in unusual sites such as limb and visceral arterial ischemia are reported rarely in the literature. Herein, we describe a rare case of a patient with severe coronavirus disease 2019 (COVID-19) infection who experienced severe abdominal pain during the hospitalization and presented simultaneously renal artery, splenic artery and vein as well as aortic thrombi despite prophylactic antithrombotic treatment. Information about his follow-up post discharge is also provided. This case report raises significant clinical implications regarding the correct dose of antithrombotic treatment during the acute phase of the severe COVID-19 infection and highlights the need for incessant vigilance in order to detect thrombosis at unusual sites as a possible diagnosis when severe abdominal pain is present in severe COVID-19 patients.

Oral anticoagulant treatment after bioprosthetic valvular intervention or valvuloplasty in patients with atrial fibrillation—A SWEDEHEART study

Aims To describe the prevalence of atrial fibrillation (AF), use of oral anticoagulants (OAC) and change in antithrombotic treatment patterns during follow-up after valve intervention with a biological prosthesis or valvuloplasty. Methods and results All patients with history of AF or new-onset AF discharged alive after valvular intervention (biological prosthesis or valvuloplasty) between 2010–2016 in Sweden were included (n = 7,362). Information about comorbidities was collected from national patient registers. Exposure to OAC was based on pharmacy dispensation data. In total 4,800 (65.2%) patients had a history of AF, and 2,562 (34.8%) patients developed new-onset AF, with 999 (39.0%) developing new-onset AF within 3 months after intervention. The proportion of patients with biological valve prosthesis was higher in patients with new-onset AF compared to history of AF (p<0.001). CHA2DS2-VASc score ≥2 was observed in 83.1% and 75.5% patients with history of AF and new-onset AF, respectively. Warfarin was more frequently dispensed than NOAC at discharge in patients with history of AF (43.9% vs 7.3%), and in patients with new-onset AF (36.6% vs 17.1%). Almost half of the AF population was not dispensed on any OAC at discharge (48.8% in patients with history of AF and 46.3% in patients with new-onset AF). Conclusion In this real world study of patients with AF and recent valvular intervention, risk of new-onset AF after valvular intervention is high emphasizing need for frequent rhythm monitoring after intervention. A considerable undertreatment with OAC was observed despite being indicated for the majority of the patients. Warfarin was the OAC most frequently dispensed.

Anticoagulation Prior to COVID-19 Infection Has No Impact on 6 Months Mortality: A Propensity Score–Matched Cohort Study

The coronavirus disease 2019 (COVID-19) shows high incidence of thromboembolic events in humans. In the present study, we aimed to evaluate if anticoagulation prior to COVID-19 infection may impact clinical profile, as well as mortality rate among patients hospitalized with COVID-19. The study was based on retrospective analysis of medical records of patients with laboratory confirmed SARS-CoV-2 infection. After propensity score matching (PSM), a group of 236 patients receiving any anticoagulant treatment prior to COVID-19 infection (AT group) was compared to 236 patients without previous anticoagulation (no AT group). In 180 days, the observation we noted comparable mortality rate in AT and no AT groups (38.5% vs. 41.1%, p = 0.51). Similarly, we did not observe any statistically significant differences in admission in the intensive care unit (14.1% vs. 9.6%, p = 0.20), intubation and mechanical ventilation (15.0% vs. 11.6%, p = 0.38), catecholamines usage (14.3% vs. 13.8%, p = 0.86), and bleeding rate (6.3% vs. 8.9%, p = 0.37) in both groups. Our results suggest that antithrombotic treatment prior to COVID-19 infection is unlikely to be protective for morbidity and mortality in patients hospitalized with COVID-19.

Intractable Progressive Cerebral Infarction with Multiple Atypical Aneurysms in Systemic Lupus Erythematosus

We report a case of intractable progressive cerebral infarction with multiple fusiform aneurysms in a 34-year-old female patient with systemic lupus erythematosus (SLE), non-responsive to massive immunotherapy. The patient visited the emergency department with dysarthria and left-sided hemiparesis that occurred 2 days before. She was diagnosed with SLE involving the brain and received 12 cycles of cyclophosphamide 12 years prior. Brain diffusion-weighted imaging showed acute infarctions involving the pons and medulla. Additionally, multifocal microbleeding-like signals in various cisternal spaces were detected using susceptibility-weighted imaging. Digital subtraction angiography revealed multiple fusiform aneurysms. Despite antithrombotic treatment with trif lusal and immunotherapies, including corticosteroids, mycophenolate mofetil, and immunoglobulins, for cerebral vasculitis associated infarction, her neurologic deficits worsened with recurrent cerebral infarction. Further investigation for accurate diagnosis and treatment is required.

A retrospective analysis of fibrinolytic and adjunctive antithrombotic treatment during cardiopulmonary resuscitation

Synergistic effects of fibrinolytic and additional antithrombotic treatment during cardiopulmonary resuscitation in out-of-hospital cardiac arrest of assumed cardiac origin were evaluated retrospectively. Data were drawn from electronic files of the physician-staffed Emergency Medical Services Tyrol. During a 22-month observation period 53 adult patients were treated with tenecteplase (mean 7641 IU), 19 (32.1%) of whom received additional antithrombotic treatment with heparin (4000–5000 IU) and acetylsalicylic acid (250–500 mg). Lasting return of spontaneous circulation occurred in four of 34 patients who received fibrinolytic treatment only and in seven of 19 patients with additional antithrombotic treatment (p = 0.037). Four of five patients who were discharged from hospital had received additional antithrombotic treatment during CPR and were in appropriate neurological status (CPC 1). Considering the small sample size in this retrospective study, the argument may be still be made that fibrinolytic and adjunctive antithrombotic treatment during cardiopulmonary resuscitation in out-of-hospital cardiac arrest of assumed cardiac origin may increase the chances for survival.

Perioperative Safety of Gastrectomy for Patients Receiving Antithrombotic Treatment

Background: With the aging population, more patients are expected to receive antithrombotic treatment. Although many studies have investigated the perioperative management of antithrombotic therapy, few have targeted gastrectomy. Hence, the safety of gastrectomy for patients receiving antithrombotic agents remains unclear. This retrospective cohort study sought to compare outcomes between patients who did and did not receive antithrombotic agents.Methods: This single-center retrospective cohort study included 548 patients who underwent gastrectomy for primary gastric adenocarcinoma from January 2011 to December 2019. Patients were subsequently classified into two groups according to whether they received antithrombotic therapy (n = 121) or not (n = 427), after which surgical outcomes were compared. Propensity score analysis was performed based on age, sex, body mass index, open versus laparoscopic surgery, and total versus distal gastrectomy. After propensity score matching, 121 patients were included in each group.Results: Among the entire cohort, receiving antithrombotic therapy group was significantly older than those who did not (age ≥ 75 years, 48% vs. 33%; p ≤ 0.0001). Those receiving antithrombotic therapy had significantly higher postoperative complication rates than those who did not (33.1% vs. 23.9%; p = 0.046). After matching, no significant difference in the postoperative complication rate was observed between both groups.Conclusion: Despite having a high risk for postoperative complications, patients receiving antithrombotic therapy can safely undergo gastric resection.