Evaluation of the SAMe-TT2R2 score to predict the quality of anticoagulation control in patients after Mitral Valve Replacement

Background:This study aimed to evaluate the role of SAMe-TT2R2 score in the prediction of anticoagulation control after mechanical mitral valve replacement.Methods and Results:We retrospectively reviewed clinical data of 161 patients who received mechanical mitral valve replacement at Beijing Anzhen Hospital from January 2013 to December 2013. Collected data included general information of patients, medication and smoking, postoperative embolism due to anticoagulant, bleeding complications and death information. In the SAMe-TT2R2 score results, the lowest score was 2 points (6.3%), the highest score was 7 points (0.7%). The number of people with 4 points was the largest ,60 people (41.4%).When the cut-off value of SAMe-TT2R2 score was set to ≥4, the sensitivity and specificity of predicting TTR≥65% were 69.8% and 93.1%, respectively. The Youden index was 0.629. If the cut-off value of SAMe-TT2R2 score was set to ≤4, the sensitivity and specificity of predicting TTR≥65% were 93.0% and 44.1%, respectively, and the Youden index was 0.371.ROC curve evaluates the predictive power of the SAMe-TT2R2 score for TTR≥65%. The figure showed that when the cut-off point≥4, the best combination of sensitivity and specificity was shown (69.8% and 93.1%, respectively).The area under the curve AUC was 0.854.Conclusions:After mechanical mitral valve replacement, the SAME-TT2R2 model can effectively predict the level of TTR during the course of using oral warfarin anticoagulation, and the SAMe-TT2R2 score ≥4 can be used to predict TTR<65%.

Anticoagulation for Radiation-Induced Optic Neuropathy

Radiation-induced optic neuropathy (RION) is a severely disabling complication of radiotherapy, without any known effective treatment. Three patients, one female and two males, aged 60, 34, and 45 years, respectively, developed progressive deterioration in visual acuity over 1 month, 8 years, and 2 months, starting 3, 12, and 9 years after radiotherapy for nasopharyngeal carcinoma. They received 70.15, 60.89, and 56.11 Gy over a period of 6–7 weeks, with fractionated doses of 2, 1.79, and 1.81 Gy, respectively. Ophthalmological examination revealed a relative afferent pupillary defect in the latter 2 patients, best-corrected visual acuity was 6/12 or better in all. Visual field charting showed a superior altitudinal field defect in the first two, and generalised visual loss in the third patient in the symptomatic eyes. Anticoagulation with heparin bridging and oral warfarin with an INR target of 2.0–3.0 was commenced within 2 months of symptom onset. All showed improvement in visual fields within 2 weeks, and remained stable for at least 2 years while on warfarin. Our encouraging findings will need to be confirmed in a randomised controlled clinical trial.

A Case Report on Warfarin Induced Skin Necrosis: Drug-drug Interaction or Inappropriate Therapy

Introduction: Warfarin is one of the most frequently prescribed oral anticoagulant. Necrosis and/or gangrene ofskin and other tissues is an uncommon but serious risk associated with warfarin. The incidence of warfarin inducedtissue necrosis is about 0.01 % to 0.1%.Case description: A 62-year-old male presented to emergency with a complaint of skin discoloration and edema onleft lower limb diagnosed as warfarin induced skin necrosis. He had an episode of hemiparesis 20 days back for whichhe was started on oral warfarin along with other medications. On diagnosis warfarin was stopped and fresh frozenplasma (FFP) was given along with vitamin K. Due to progressing tissue necrosis, above knee limb amputation wasdone. We assume that an interaction between rosuvastatin and warfarin or possibly lack of adequate bridge therapywith heparin resulted in this complication.Conclusion: Warfarin induced skin necrosis is a known early complication of the therapy. Though late onsetappearance of this event is rare but not unknown. Bridging therapy with heparin and avoiding use of interactingdrugs concomitantly could prevent many such reactions.

P.056 Intracranial hemorrhage as initial presentation of sagittal sinus thrombosis: review of 3 cases

Background: Intracranial hemorrhage due to sagittal sinus thrombosis is an unusal inital clinical presentation and a series of 3 cases is presented. Methods: A retrospective study of stroke patients seen at the William Osler Health System between 2014 -2016. Results: 1: 43 y.o. female presented with headaches and right hemiparesis. CT and MRI/MRV showed L. parietal intra-cerebral hemorrhage and sagittal and transverse sinus thrombosis. She was treated with IV heparin and subsequent oral Warfarin but developed symptomatic left subdural hematoma which was successfully evacuated. Hypercoagulable workup was negative. Subsequent MRI/MRV showed resolution of her sinus thrombosis and received asparin only since. 2: 45 y.o. male presented with generalized seizure 10 days following a motor vehicle accident. Initial CT showed focal right frontal subarachnoid hemorrhage and subsequent MRI/MRV confirmed extensive sagittal sinus thrombosis. He was treated with IV heparin and subsequent Warfarin without any complications. 3: 32 y.o. male presented with generalized seizure. CT and MRI/MRV confirmed a large right temporal lobe intra-cerebral hemorrhage and extensive right transverse sinus and straight sinus thrombosis. He was successfully treated with IV heparin followed by oral Warfarin. Conclusions: Despite intracranial hemorrhage in patients with cerebral sinus venous thrombosis, they could be managed successfully with anticoagulation therapy and with careful clinical and neuro-imaging monitoring.