Thrombose et TAVI : beaucoup de questions restent sans réponses.

Over the past decade, TAVI has become the standard technique for treatment of severe symptomatic aortic stenosis in patients at high or intermediate surgical risk and more recently in low-surgical-risk patients. Like any technique, TAVI is associated with certain complications such as post-TAVI thrombosis. This complication can have clinical manifestations with recurrence of symptoms and/or increase in trans-prosthetic gradients. It can also be infraclinical, i.e asymptomatic without trans-prosthetic gradient elevation as revealed by cardiac CT scan showing a thickening of the valvular leaflets or cusp thrombosis, with potential impairment of the valve opening. This greatly underestimated complication has a 10% to 15% incidence. Biomechanical factors, intrinsic patient-related predisposition as well as post-TAVI anti-thrombotic treatment have all been incriminated in the occurrence of TAVI thrombosis. The use of anticoagulation treatment by AVK or DOAC in the presence of post TAVI prosthetic thrombosis seems obvious. However, their benefit in the treatment of infraclinical thrombosis has not been clearly established.

[Libman-Sacks endocarditis under apixaban in a patient with a high-risk profile venous antiphospholipid syndrome]. / Une endocardite de Libman-Sacks survenant sous apixaban chez une patiente atteinte de SAPL veineux de profil à haut risque.

INTRODUCTION: Libman-Sacks endocarditis is a rare complication of antiphospholipid syndrome. Anti-vitamin K therapy is the standard treatment, although valvular replacement surgery may be required in some severe cases. In the latest EULAR recommendations, it is advised not to use direct oral anticoagulants in the management of antiphospholipid syndrome, especially of high-risk profile. CASE REPORT: We present a case of a mitral Libman-Sacks endocarditis complicated with multiple strokes occurring in the setting of an antiphospholipid syndrome with triple positive antibody profile in a 63-year-old woman with multiple sclerosis. She was previously treated with apixaban for two years. Tinzaparin followed by prolonged warfarine treatment and two months of hydroxychloroquine resulted in valvular improvement. CONCLUSION: To our knowledge, this is the first case of Libman-Sacks endocarditis occurring during apixaban therapy in a patient with antiphospholipid syndrome. This severe case highlights the inefficiency of direct oral anticoagulants to prevent thrombotic events in the antiphospholipid syndrome.

Effect of oral anticoagulation on clinical outcomes and haemodynamic variables after successful transcatheter aortic valve implantation.

BACKGROUND: The effect of oral anticoagulation on clinical and haemodynamic outcomes following successful transcatheter aortic valve implantation is unclear. AIMS: To evaluate the effect of oral anticoagulation within the first year after transcatheter aortic valve implantation. METHODS: All patients undergoing transcatheter aortic valve implantation in two French tertiary centres from 2010 to 2016 were included prospectively. The composite outcome of death, stroke, readmission for heart failure or major/life-threatening bleeding according to Valve Academic Research Consortium 2 criteria within 1year was evaluated. Valvular haemodynamic deterioration was defined as mean transprosthetic gradient ≥20mmHg or an increase of ≥10mmHg during echocardiographic follow-up. RESULTS: Of the 1139 patients included, 400 (35.1%) were discharged on oral anticoagulation. The primary endpoint was more frequent in the group with versus without oral anticoagulation (29.4% vs. 17.3% 21.5%; hazard ratio 1.83, 95% confidence interval 1.42-2.35). Composite endpoint risk factors were chronic pulmonary and kidney diseases, previous atrial fibrillation, left ventricular ejection fraction ≤30% at discharge and no femoral vascular approach, but not oral anticoagulation prescription at discharge. Conversely, 58 patients were identified with valvular haemodynamic deterioration, including 11 (19%) in the group with oral anticoagulation and 47 (81%) in the group without oral anticoagulation. Valvular haemodynamic deterioration risk factors were absence of oral anticoagulation exposure, increased body mass index, use of a balloon-expandable bioprosthesis and use of a bioprosthesis with diameter ≤23mm. Antithrombotic treatment crossover (i.e. oral anticoagulation interruption or introduction during follow-up) occurred in 9.6% of patients, and was a risk factor for death (adjusted hazard ratio 3.39, 95% confidence interval 1.63-7.07). CONCLUSIONS: Baseline characteristics, rather than oral anticoagulation prescription at discharge, were associated with adverse outcomes following successful transcatheter aortic valve implantation. Conversely, oral anticoagulation was associated with reduced valvular haemodynamic deterioration.

[Anticoagulation in Venous Thromboembolism: How Long and Which Dose?] / Antikoagulation bei venöser Thromboembolie: wie lange und welche Dosierung?

Anticoagulation in Venous Thromboembolism: How Long and Which Dose? Abstract. Venous thromboembolism is quite common in daily practice. As soon as the diagnosis is confirmed, anticoagulation should be started immediately. Nowadays DOACs are the first choice for treatment of VTE. An important issue is the duration of anticoagulation in an individual patient. Generally, the anticoagulation should be continued for at least three months in any patient. While anticoagulation can be safely stopped after three months in patients with isolated distal DVT it should be continued for an unlimited period in persons with unprovoked proximal DVT and PE. In the vast majority of cases making that decision is not straightforward. Decision making involves assessing risks and benefits on an individual basis. Another important issue is dose reduction of the DOACs during treatment. The goal of this article is to show the factors that must be considered for decision making.

[Roles of the general practitioner and the vascular medicine physician for patient education concerning venous thromboembolism: The patient's perspective]. / Évaluation par le patient du rôle du médecin traitant et du médecin vasculaire dans l'information médicale des patients souffrant d'une maladie thromboembolique veineuse.

INTRODUCTION: Venous thromboembolism (pulmonary embolism and deep-vein thrombosis) is a frequent, serious but also chronic disease. Studies reported that both general practitioners (GPs) and vascular medicine physicians (VMPs) report participating in patient education concerning venous thromboembolic disease. OBJECTIVE: To assess the role of GPs and VMPs in venous thromboembolic disease patient education, examining the patient's perspective. METHOD: Phone survey of the French patients recruited in the CACTUS trial assessing anticoagulant treatment in case of first distal deep-vein thrombosis. RESULTS: Among the 103 participating patients, 92% (n=95) reported being satisfied by information provided by the GP and VMP. Information was considered as necessary in 96% of cases (n=99). Eighty-five percent of patients (n=88) felt they did not need complementary information. The VMP would have spent more time on education as compared with the GP (an entire consultation in 93.2% vs. 38.8% of cases respectively) the information provided by the VMP being also clearer and more complete. More than 75% of patients reported that no physician warned them about risks of anticoagulants, long-term complications of venous thromboembolic disease or its prevention. CONCLUSION: In CACTUS, patients reported being satisfied by information provided by their managing physicians and information provided by the VMP was clearer and more complete. Important education messages may not have been delivered suggesting the need for a standardization of venous thromboembolic disease patient's education.

Risk of thromboembolic complications in adult congenital heart disease: A literature review.

Adult congenital heart disease (ACHD) is a constantly expanding population with challenging issues. Initial medical and surgical treatments are seldom curative, and the majority of patients still experience late sequelae and complications, especially thromboembolic events. These common and potentially life-threating adverse events are probably dramatically underdiagnosed. Better identification and understanding of thromboembolic risk factors are essential to prevent long-term related morbidities. In addition to specific situations associated with a high risk of thromboembolic events (Fontan circulation, cyanotic congenital heart disease), atrial arrhythmia has been recognized as an important risk factor for thromboembolic events in ACHD. Unlike in patients without ACHD, thromboembolic risk stratification scores, such as the CHA2DS2-VASc score, may not be applicable in ACHD. Overall, after a review of the scientific data published so far, it is clear that the complexity of the underlying congenital heart disease represents a major risk factor for thromboembolic events. As a consequence, prophylactic anticoagulation is indicated in patients with complex congenital heart disease and atrial arrhythmia, regardless of the other risk factors, as opposed to simple heart defects. The landscape of ACHD is an ongoing evolving process, and specific thromboembolic risk scores are needed, especially in the setting of simple heart defects; these should be coupled with specific trials or long-term follow-up of multicentre cohorts.

[Left atrial appendage occlusion in elderly]. / Fermeture d'auricule gauche percutanée chez le sujet âgé.

Left atrial appendage occlusion (LAAO) is an alternative option to oral anticoagulation therapy in patients with non-valvular atrial fibrillation. According to French regulations, this procedure is currently reserved for patients with formal contraindications to VKA and direct thrombin inhibitors. LAAO procedures reduce ischemic and stroke risks compared to no treatment and also reduce bleeding events compared to VKA therapy in eligible patients. The peri-procedural complications risk has been reported to be limited in the different series published so far. Although elderly patients (>75 years) have either higher ischemic and bleeding risk than younger subjects, they hardly benefit from optimal anticoagulation. Thus, these subjects might greatly benefit from LAAO. Published studies reported excellent feasibility and efficiency of LAAO procedure in elderly patients. Yet there is a trend towards a higher incidence of peri-procedural complications (including tamponade), long-term safety is excellent and comparable to what is observed in patients<75 years. Therefore, interventional percutaneous LAAO is an attractive strategy in elderly patients with atrial fibrillation that should be incorporated in a multidisciplinary management.

[Lower limb arterial thrombosis in a nephrotic syndrome]. / Thrombose artérielle du membre inférieur sur un syndrome néphrotique.

Thromboembolic complications are frequent in the nephrotic syndrome. Arterial localizations have been rarely reported. There is no consensus on their management; it depends on the location and hypercoagulable state. We report a case of acute lower limb ischemia occurring in children with a history of nephrotic syndrome, complicated by toes necrosis. The diagnosis was made by Doppler ultrasonography. Thrombectomy was performed and the patient received an anticoagulant treatment. Local cares have improved the local state, avoiding surgical necrosectomy.

[Management of venous thromboembolism: A 2015 update]. / Prise en charge de la maladie thromboembolique veineuse en 2015.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) constitute venous thromboembolic disease (VTE). Venous thromboembolic disease is a common, serious, and multifactorial disease, the incidence of which increases with age. Risk factors, whether transient (surgery, plaster immobilization, bed rest/hospitalization) or chronic/persistent (age, cancer, clinical or biological thrombophilia, etc.), modulate the duration of treatment. In the absence of pathognomonic clinical sign or symptom, diagnostic management relies in the evaluation of the clinical pre-test probability followed by a laboratory or an imaging testing. So far, compression ultrasound and multidetector computed tomography angiography are the best diagnostic tests to make a positive diagnosis of DVT or PE, respectively. Anticoagulants at therapeutic dose for at least 3months constitute the cornerstone of VTE management. Availability of new direct oral anticoagulants, which have recently been shown to be as effective and as safe as vitamin K antagonist in clinical trials, should facilitate ambulatory management of VTE and favour extended treatments for individuals with unprovoked VTE or VTE provoked by a chronic/persistent risk factor.

[Anticoagulation in the aged patient with atrial fibrillation: What are prescribing cardiologists, geriatricians and general practitioners?]. / L'anticoagulation du patient âgé en fibrillation atriale: que prescrivent les cardiologues, les gériatres et les médecins généralistes?

OBJECTIVE: To assess prescribing of anticoagulants in atrial fibrillation (AF) in the elderly, both a quantitative point of view (rate of anticoagulation) and qualitative (type of anticoagulation). Determinants of prescribing and non-prescribing were also analysed. METHODS: Prospective survey of practice, based on one clinical case and questionnaire conducted in 60 practitioners (20 cardiologists [C], 20 geriatricians [G] and 20 general practitioners [GP]). RESULTS: In reading the clinical case, 88.3% of physicians would have initiated a treatment; three types of treatments would have been chosen: AVK (68.3%), ODA (20.0%) and platelet antiaggregant (11.7%). Criteria taken into account to initiate anticoagulation varied according to the specialty. Cardiologists considered more the age criteria (C: 95.0%, G: 75.0%, MG: 60.0%; P<0.05), diabetes (C: 90.0%, G: 60.0%, MG: 55.0%; P<0.05), hypertension (C: 85.0%, G: 55.0%, MG: 60.0%; P<0.05) and female gender (C: 80.0%, G: 35.0%, MG: 25.0%; P<0.05). The quality of renal function was however a more secondary criteria (C: 15.0%, G: 5.0%, MG: 0.0%; P<0.05). General practitioners considered most frequently the presence of underlying heart disease (C: 35.0%, G: 5.0%, MG: 45.0%; P<0.05) as well as usual cardiovascular risk factors (overweight, dyslipidaemia; P<0.05). Risk of bleeding, however, was observed by 76.7% of physicians in the clinical situation presented (C: 70.0%, G: 75.0%, MG: 85.0%; P<0.05). CONCLUSION: This survey confirms that the FA remains under anticoagulated in the elderly and the barriers to the prescription of oral anticoagulation are often without rational basis.

Effective diagnosis and treatment of pulmonary embolism: Improving patient outcomes.

Pulmonary embolism can be life threatening and difficult to diagnose as signs and symptoms are not specific. European guidelines recommend stratification of pulmonary embolism by risk of early mortality. Patients with suspected pulmonary embolism should be assessed for clinical probability of pulmonary embolism using a validated risk score. A low or intermediate clinical probability plus a negative high-sensitivity D-dimer test excludes pulmonary embolism. Anticoagulation is indicated in patients with a positive multidetector computed tomography or high-probability lung scan. An important part of the management of patients with pulmonary embolism has traditionally been anticoagulant treatment with parenteral heparins and oral vitamin K antagonists. Although effective, this dual-drug approach is associated with limitations. Direct oral anticoagulants that may overcome some of these problems have been tested in phase III clinical trials for the treatment of venous thromboembolism. Of these, rivaroxaban and apixaban have demonstrated non-inferiority to standard therapy when given as single-drug approaches for venous thromboembolism treatment, and provided significant reductions in major bleeding rates. Dabigatran and edoxaban were non-inferior to standard therapy when given as part of a dual-drug approach after initial parenteral anticoagulation, and reduced clinically relevant bleeding rates. There may be a benefit to extended anticoagulation with direct oral anticoagulants for the prevention of recurrent venous thromboembolism. Registry studies will provide more information on the use of these agents in real-world populations. Accurate diagnosis and risk stratification of patients with pulmonary embolism, together with simplified anticoagulation therapy, is likely to improve outcomes.

[Interventional prevention of ischemic stroke]. / Traitement préventif non médicamenteux des accidents thromboemboliques (AVC ischémiques).

Stroke is an extremely common condition, the important functional and financial impact of which requires intense prevention policy. This strategy includes the prevention of thromboembolic complications of atrial fibrillation. The management of atrial fibrillation includes risk stratification for stroke with theCHA(2)DS(2)VASc score and assessment of hemorrhagic risk with HASBLED score. The reference preventive treatment is anticoagulant therapy with vitamin K antagonists. Nevertheless, many patients potentially eligible for this treatment will not benefit from it, because of a high risk of bleeding, or because recurrence of thromboembolism occurs despite well-conducted anticoagulation. A new alternative intrventional treatment has been proposed for these clinical situations: left atrial appendage percutaneous closure. Several studies examined the feasibility, effectiveness and safety of three devices: the device PLAATO the WATCHMAN(©), and AmplatzerCardiacPlug™. The prospective multicenter randomized PROTECT-AF study demonstrated non-inferiority of the WATCHMAN(©) device compared to conventional warfarin therapy. Yet a medical reflection is still needed to determine the target population which may actually benefit from interventional treatment. Currently, clinical evaluation programs have begun in France with the aim to clarify the indication of non-drug preventive treatment of stroke.

[Fetal taking in some particular circumstances]. / Prélèvements fœtaux : à propos de quelques situations problématiques.

Fetal takings still concern about 6 to 7% of the pregnancies. If, in the majority of the cases, the taking does not present difficulty for a trained operator, particular circumstances related to maternal context (anticoagulating treatment, vaginal bleeding, fever…) may make the taking become more difficult. From a questionnaire sent to the French multidisciplinary centers for prenatal diagnosis and a review of the literature, we establish guidelines for fetal taking in these circumstances.