RESUMO
We present a case of a patient undergoing aortic valve replacement being inadvertently administered 5000 U of bovine thrombin instead of heparin for anticoagulation for cardiopulmonary bypass. The labeling error was made within the operating room pharmacy. The key to survival of this patient was a rapid diagnosis, administration of antithrombin and heparin, and removal of cardiac and great vessel thrombi. It is recommended that point of care anesthesia providers `prepare heparin for cardiopulmonary bypass anticoagulation, as thrombin is not used in anesthetic practice and is not contained within anesthesia cabinet medication drawers.
Assuntos
Hemostáticos/efeitos adversos , Erros de Medicação , Pré-Medicação , Trombina/efeitos adversos , Idoso , Ponte Cardiopulmonar , Feminino , Hemostáticos/administração & dosagem , Humanos , Trombina/administração & dosagemRESUMO
Mitral valve repair is a feasible and preferable option for the treatment of Barlow's disease. Complex valve repair techniques, in contrast, often lead to increased cross-clamp times and low cardiac output syndrome. A simple, fast, and reproducible foldoplasty technique to reduce anterior and posterior mitral leaflet heights may improve coaptation and reduce mitral regurgitation. Accordingly, herein are described minimally invasive, successful trans-septal and robotic approaches for a bileaflet foldoplasty technique in two patients with Barlow's disease.
Assuntos
Implante de Prótese de Valva Cardíaca/métodos , Anuloplastia da Valva Mitral/métodos , Prolapso da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Procedimentos Cirúrgicos Robóticos , Técnicas de Sutura , Toracotomia , Adulto , Ecocardiografia Doppler em Cores , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Hemodinâmica , Humanos , Pessoa de Meia-Idade , Valva Mitral/anormalidades , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Anuloplastia da Valva Mitral/instrumentação , Prolapso da Valva Mitral/diagnóstico por imagem , Prolapso da Valva Mitral/fisiopatologia , Resultado do TratamentoRESUMO
This case study reports the operative management of a 63-year-old male patient following implantation of the HeartMate II (HMII) left ventricular assist device (LVAD), with a non-compliant left ventricle (LV) and a reduced right ventricular (RV) end-diastolic volume. Intraoperatively, the patient had a thin, fragile LV wall with laminated clot; a ventricular septal defect was encountered during removal of the clot. Along with an aortic valve repair, the LV and the septum were reconstructed with multiple bovine pericardium patches, thus, moderately reducing the RV and LV stroke volume. A difference in cardiac output via a Swan-Ganz catheter (approximately 1.5 l/min) was observed as opposed to the HMII's estimated flow. The result was later replicated and verified ITALIC! in vitrovia the Donovan Mock Circulation System (DMCS), where about 2 l/min lower flow on the HMII system was observed. In conclusion, the HMII flow rate displayed can be inaccurate and should only be used for trending.
Assuntos
Comunicação Interventricular , Ventrículos do Coração , Coração Auxiliar , Falha de Prótese , Animais , Bovinos , Comunicação Interventricular/fisiopatologia , Comunicação Interventricular/cirurgia , Ventrículos do Coração/fisiopatologia , Ventrículos do Coração/cirurgia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
A central coaptation stitch (Park's stitch) is a simple surgical option in the management of aortic insufficiency in patients with left ventricular assist devices. We describe a 66-year-old male with aortic insufficiency and a bicuspid aortic valve undergoing left ventricular assist device implantation. His aortic insufficiency was successfully addressed with a Park's stitch.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/anormalidades , Procedimentos Cirúrgicos Cardíacos/métodos , Doenças das Valvas Cardíacas/cirurgia , Ventrículos do Coração , Coração Auxiliar , Idoso , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/terapia , Doença da Válvula Aórtica Bicúspide , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/terapia , Humanos , Masculino , Resultado do TratamentoRESUMO
BACKGROUND Effusive-constrictive pericarditis (ECP) is an uncommon clinical syndrome characterized by the coexistence of pericardial effusion and constriction involving the visceral pericardium. This differs from constrictive pericarditis, which presents with thickening of the pericardium without effusions. Specific diagnostic criteria of ECP include the failure of right atrial pressure to decrease by 50% or reach a new level below 10 mmHg after normalization of intrapericardial pressure. CASE REPORT We present the case of a 32-year-old obese man with multiple comorbidities who initially presented with flu-like symptoms and pleural effusion with development of constrictive-like symptoms. Despite undergoing numerous pericardiocentesis and appropriate medical management, the patient's condition failed to improve, leading to the likely diagnosis of effusive-constrictive pericarditis. Cultures of pericardial fluid revealed E. -faecium, which required multiple antimicrobial therapy. Despite infection, the exact etiology of ECP remained unknown and likely idiopathic. Common causes of ECP include idiopathic, tuberculosis, cardiac surgery complications, radiation, or neoplasia. Ultimately, the patient underwent a pericardiectomy involving the visceral and parietal pericardium, resulting in hemodynamic stability and resolution of symptoms. CONCLUSIONS This case highlights the challenges in diagnosing and managing ECP, emphasizing the importance of considering surgical intervention in refractory cases. ECP initially presents as a pericardial effusion, often addressed through pericardiocentesis; however, in a small subset of patients, sustained symptoms and altered hemodynamics persist following pericardiocentesis, necessitating further evaluation and management. The success of pericardiectomy in our patient highlights the potential efficacy of surgical intervention in improving outcomes for patients with ECP.
Assuntos
Derrame Pericárdico , Pericardiectomia , Pericardite Constritiva , Humanos , Pericardite Constritiva/cirurgia , Pericardite Constritiva/diagnóstico , Masculino , Adulto , Derrame Pericárdico/cirurgia , Derrame Pericárdico/etiologia , Derrame Pericárdico/diagnósticoRESUMO
Background: Pump thrombosis is a serious complication of continuous-flow left ventricular assist device (CF-LVAD) therapy. In this study, we aim to report a novel protocol of an intermittent, low-dose, and slow infusion of tissue plasminogen activator (alteplase). Case summary: We treated seven LVAD pump thrombosis events (HeartMate® II and HeartWare) in four patients with a median age of 52 years (31-63), and all were female. The protocol was applied from January 2015 to December 2018, and it consisted of an intermittent, low-dose, and slow infusion of systemic thrombolytic therapy in the intensive care unit. This therapy resulted in successful resolution of pump thrombosis in six out of seven events. Bleeding complication occurred in one patient, which included a ruptured haemorrhagic ovarian cyst and a small cerebellar intra-parenchymal haemorrhage. All patients were discharged home in a stable condition, except one patient who died during hospitalization because of severe sepsis, pump thrombosis with subsequent pump exchange, and multi-organ failure. Discussion: A low-dose, prolonged, and systemic thrombolytic infusion protocol is an effective and relatively safe treatment that can lead to a sustained resolution of pump thrombosis with low bleeding complications and failure rates.
RESUMO
The epidemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has had a significant global impact, especially on immunosuppressed populations such as heart transplant recipients. While SARS-CoV-2 initially infects the respiratory system, cardiovascular complications induced by coronavirus disease 2019 (COVID-19) include cardiac arrest, myocardial infarction, heart failure, myocarditis, arrhythmia, acute myocyte injury, thrombotic events, and cardiogenic shock. Here, we present a case of a 45-year-old African American male who tested positive for COVID-19 infection six months after receiving a heart transplant. The patient was asymptomatic initially, but two weeks later he developed dyspnea, early satiety, and abdominal bloating. The patient was admitted to the hospital for acute renal failure and subsequently diagnosed with moderate acute T cell-mediated allograft rejection (Grade 2R) by endomyocardial biopsy. Three months after testing positive for COVID-19, the patient suffered a sudden cardiac death. At autopsy, the epicardium was diffusely edematous and showed vascular congestion. The coronary arteries showed a striking concentric narrowing of lumens and diffusely thickened arterial walls of all major extramural arteries deemed consistent with a rapidly progressive form of cardiac allograft vasculopathy (CAV). SARS-CoV-2 nucleocapsid protein was localized by immunohistochemistry (IHC) in endothelial cells of venules and capillaries within the epicardium. Our localization of SARS-CoV-2 in coronary vessel endothelial cells by IHC suggests that endothelial cell infection, endotheliitis, and immune-related inflammation may be a primary mechanism of vascular injury. The present case represents an early onset rapidly progressive form of CAV. This case may be the first case of post-transplant arteriopathy occurring in such a short time that includes corresponding autopsy, surgical pathology, and IHC data.
Assuntos
COVID-19 , Transplante de Coração , Humanos , COVID-19/complicações , Transplante de Coração/efeitos adversos , Masculino , Pessoa de Meia-Idade , Evolução Fatal , Rejeição de Enxerto/patologia , Rejeição de Enxerto/imunologia , SARS-CoV-2/patogenicidade , Progressão da Doença , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/patologia , Doença da Artéria Coronariana/patologia , Doença da Artéria Coronariana/etiologiaRESUMO
CONTEXT.: During platelet shortages, many hospitals produce low-dose platelets by splitting a standard platelet unit (>3 × 1011 platelets in the United States) in 2, then providing these low-dose units to patients. While low-dose units were previously found to be effective for prophylactic purposes in patients undergoing chemotherapy in the Prophylactic Platelet Dose (PLADO) trial, their use in actively bleeding patients has not yet been assessed. OBJECTIVE.: To assess the use and safety of low-dose platelets in actively bleeding patients. DESIGN.: We performed a retrospective review of cardiac surgery cases receiving platelet units for 18 months at 1 hospital. Two cohorts, those receiving only whole-dose platelets (37 cases) and those receiving only low-dose platelets (38 cases), were compared during the intraoperative and the 24-hour perioperative period. Mean number of platelet transfusions, dose of other blood products, estimated blood loss, bleeding complications in index cases, and all-cause mortality within 30 days of discharge were compared. RESULTS.: There was no significant difference in mean number of intraoperative platelet transfusions between the cohorts (1.61 versus 1.53, P = .57). There was no significant increase in the transfusion of other blood products, estimated blood loss, bleeding complications in index cases, or all-cause mortality within 30 days of discharge in the low-dose platelet cohort, apart from a small increase in requirement for fresh frozen plasma in the perioperative period. CONCLUSIONS.: These results suggest that low-dose platelets are tentatively equivalent to whole-dose platelets in cardiac surgery during shortages, with similar transfusion requirements and clinical outcomes between groups. Future multicenter studies are needed to confirm these findings.
RESUMO
A 60-year-old hypertensive male with non-ST segment elevation myocardial infarction had a hyperdynamic LV with mild posterior leaflet mitral valve prolapse without significant regurgitation on transthoracic echocardiogram. Two-dimensional (2D) TEE showed severe mitral regurgitation with prolapse of P2 and P3 scallops. Posteromedial papillary muscle rupture was suspected. Three-dimensional (3D) TEE demonstrated severely prolapsing P2 and P3 valve scallops with a clear view of the partially ruptured posteromedial papillary muscle. Patient underwent emergency coronary bypass and mitral valve replacement. Surgical pathology of papillary muscle confirmed coagulative necrosis. 3D TEE was superior in identifying the partial posteromedial papillary muscle rupture.
Assuntos
Ecocardiografia Tridimensional/métodos , Ruptura Cardíaca Pós-Infarto/complicações , Ruptura Cardíaca Pós-Infarto/diagnóstico por imagem , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/etiologia , Músculos Papilares/diagnóstico por imagem , Músculos Papilares/lesões , Sistemas Computacionais , Diagnóstico Diferencial , Ecocardiografia Transesofagiana/métodos , Ruptura Cardíaca Pós-Infarto/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/cirurgia , Resultado do TratamentoRESUMO
Solitary fibrous tumor (SFT) are rare pleura neoplasms often localized to middle or inferior hemithorax. A middle-aged woman presents to the emergency department following a motor vehicle accident, the computed tomography scan revealed a giant tumor occupying the entire left pleural cavity with a complete collapse of the left lung and substantial right deviation of heart and mediastinum. Using preoperative arterial coiling followed by a double-level thoracotomy we successfully resected the giant tumor. The SFT weighed ~10 lbs. At 2-month follow-up visit patient reports mild discomfort during strenuous movement/heavy lifting but denies any shortness of breath.
RESUMO
Cardiovascular disease is one of the leading causes of maternal mortality in the United States. Although still rare, pregnancy in patients with left ventricular assist devices (LVADs) is becoming more common. Typical indications for the use of LVADs in reproductive-aged females include ischemic cardiomyopathy, nonischemic (familial) dilated cardiomyopathy, peripartum cardiomyopathy, and some forms of myocarditis. An LVAD drains blood through a cannula placed into the apex of the left ventricle and then returns it to the proximal aorta bypassing the aortic valve allowing hemodynamic support in parallel with the native circulation. The physiologic changes associated with pregnancy, mainly increased blood volume and hypercoagulability, may adversely affect patients with LVADs, leading to many experts recommending against pregnancy. Maternal-fetal medicine specialists should have a central role within a multidisciplinary team required to provide optimal care for this high-risk group of patients.
Assuntos
Cardiomiopatias , Doenças Cardiovasculares , Insuficiência Cardíaca , Coração Auxiliar , Feminino , Gravidez , Humanos , Adulto , Coração Auxiliar/efeitos adversos , Hemodinâmica , Insuficiência Cardíaca/terapiaRESUMO
Objective YouTube (YouTube LLC, San Bruno, California, United States), one of the most accessed sites on the internet, has become a widespread source of healthcare information for patients. Videos about coronary artery bypass grafts (CABG) have accrued tens of millions of views on the platform, yet their educational quality is unknown. This study investigates the educational landscape of videos regarding CABG procedures on YouTube. Methods YouTube was queried for "Coronary Artery Bypass Graft Surgery" and "Coronary Artery Bypass Graft Procedure". After applying exclusion criteria, 73 videos were assessed. Two independent reviewers rated the material with the Global Quality Scale (GQS) (5 = high quality, 0 = low quality) to judge educational value. A ratio of view count to days since upload was applied to assess video popularity. Source, modality, and date of upload were recorded for each video as well. Results An average GQS score of 2.94 was found, indicating poor educational quality of the 73 YouTube videos on CABG procedures. Videos uploaded by physicians (56/73; 76.7%) had a significantly higher average GQS score than those uploaded by non-physicians (p<0.001). When content was grouped by delivery method, physician-led presentations (24/73 or 32.9%) produced the highest average GQS score of 3.35; conversely, patient-friendly delivery methods (18/73 or 24.7%) yielded the lowest average GQS score of 2.36 (p<0.001). Neither the view ratio nor the days since upload significantly correlated with the educational quality of the video. Conclusion Although CABG videos are readily available on YouTube, they often contain considerable biases and misleading information. With online sources for healthcare education now commonplace, physicians must be aware of the vast quantities of low-quality videos patients often encounter when weighing different treatment options. Further analysis of CABG videos on YouTube may allow physicians to ameliorate this gap by producing videos that are not only high quality but highly viewed on the platform.
RESUMO
Increasingly, patients undergo heart transplant after previous heart surgery. In patients with a persistent left superior vena cava (LSVC), the preferred technique, preservation of drainage via the native coronary sinus, can be difficult in reoperative cases due to adhesions. We report a technique simplifying this operation in such a patient.
Assuntos
Transplante de Coração , Procedimentos Cirúrgicos Vasculares/métodos , Veia Cava Superior/cirurgia , Seio Coronário , Humanos , Masculino , ReoperaçãoRESUMO
Our study assessed the relationship between the duration of venovenous extracorporeal membrane oxygenation (V-V ECMO) and patient outcomes. We studied patients undergoing V-V ECMO support for acute respiratory distress syndrome (ARDS) between 2009 and 2017 who were reported to the Extracorporeal Life Support Organization registry. We evaluated survival, major bleeding, renal failure, pulmonary complications, mechanical complications, neurologic complications, infection, and duration of V-V ECMO support. Multivariable regression modeling assessed risk factors for adverse events. Of the 4,636 patients studied, the mean support duration was 12.2 ± 13.7 days. There was a progressive increase in survival after the initiation of V-VECMO, peaking at a survival rate of 73% at 10 days of support. However, a single-day increase in V-V ECMO duration was associated with increased bleeding events (odds ratio [OR] 1.038; 95% confidence interval [CI]: 1.029-1.047; p < 0.0001), renal failure (OR 1.018; 95% CI: 1.010-1.027; p < 0.0001), mechanical complications (OR 1.065; 95% CI: 1.053-1.076; p < 0.0001), pulmonary complications (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001), and infection (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001). V-V ECMO progressively increases survival for ARDS over the first 10 days of support. Thereafter, rising complications associated with prolonged durations of support result in a progressive decline in survival.
Assuntos
Oxigenação por Membrana Extracorpórea , Insuficiência Renal , Síndrome do Desconforto Respiratório , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Síndrome do Desconforto Respiratório/terapia , Razão de Chances , Taxa de Sobrevida , Insuficiência Renal/etiologia , Estudos RetrospectivosRESUMO
This study compares the morbidity and mortality at 30 days following the use of bilateral internal mammary arteries (BIMA) vs a single internal mammary artery (SIMA) at the time of coronary artery bypass grafting (CABG) in patients with a preoperative HbA1c. Patients undergoing CABG from January 2008 to December 2016 reported to the Society of Thoracic Surgeons database were retrospectively reviewed. The patients were divided into 2 groups: use of BIMA or use of SIMA and propensity matched. To assess the effect of preoperative HbA1c, both groups were further divided into 5 subgroups: patients without diabetes mellitus (DM), or patients with DM and a preoperative HbA1c level in one of four groups (< 7%, 7-9%, 9-11%, or >11%). The postoperative outcomes in both the BIMA and SIMA groups were compared. There were 700,504 and 28,115 patients with measured preoperative HbA1c levels in the SIMA and BIMA groups, respectively. Propensity score matching identified 23,635 comparable patients in each group for analysis. There was no difference in postoperative mortality between the BIMA and SIMA groups (1.3% vs 1.2%). The incidences of sternal wound infection (SWI) in patients undergoing placement of BIMA vs SIMA were: 0.8% vs 0.4% with no DM (P < 0.0001), 1.9% vs 1.0% with HbA1c < 7% (P < 0.001), 2.4% vs 1.2% with HbA1c 7-9% (P < 0.001), 2.8% vs 1.4% with HbA1c 9-11% (P = 0.02), 4.1% vs 1.5% with HbA1c > 11% (P = 0.01). Based on the incidence of SWI, BIMA is a reasonable approach with an HbA1c<7%.
Assuntos
Doença da Artéria Coronariana , Diabetes Mellitus , Artéria Torácica Interna , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/cirurgia , Humanos , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Artéria Torácica Interna/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The pathogenicity of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been attributed to its ability to enter through the membrane-bound angiotensin-converting enzyme 2 (ACE2) receptor. Therefore, it has been heavily speculated that angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy may modulate SARS-CoV-2 infection. In this study, exposure of human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs) and human endothelial cells (hECs) to SARS-CoV-2 identified significant differences in protein coding genes involved in immunity, viral response, and cardiomyocyte/endothelial structure. Specifically, transcriptome changes were identified in the tumor necrosis factor (TNF), interferon α/ß, and mitogen-activated protein kinase (MAPK) (hPSC-CMs) as well as nuclear factor kappa-B (NF-κB) (hECs) signaling pathways. However, pre-treatment of hPSC-CMs or hECs with two widely prescribed antihypertensive medications, losartan and lisinopril, did not affect the susceptibility of either cell type to SARS-CoV-2 infection. These findings demonstrate the toxic effects of SARS-CoV-2 in hPSC-CMs/hECs and, taken together with newly emerging multicenter trials, suggest that antihypertensive drug treatment alone does not alter SARS-CoV-2 infection.
Assuntos
Anti-Hipertensivos/farmacologia , Tratamento Farmacológico da COVID-19 , Células Endoteliais/efeitos dos fármacos , Miócitos Cardíacos/efeitos dos fármacos , COVID-19/genética , Células Cultivadas , Suscetibilidade a Doenças , Células Endoteliais/metabolismo , Interações Hospedeiro-Patógeno/efeitos dos fármacos , Humanos , Lisinopril/farmacologia , Losartan/farmacologia , Miócitos Cardíacos/metabolismo , SARS-CoV-2/efeitos dos fármacos , SARS-CoV-2/fisiologia , Transcriptoma/efeitos dos fármacosRESUMO
We report a simple technique of LVAD outflow anastomosis as patch closure of a standard aortotomy during left ventricular assist device (LVAD) implant. Benefits are a single aortotomy, a low graft leaving ample native aorta for transplant, a wide-open LVAD outflow, and excellent aortic valve exposure.
Assuntos
Aorta/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Coração Auxiliar , Próteses e Implantes , Anastomose Cirúrgica/métodos , Implante de Prótese de Valva Cardíaca/métodos , HumanosAssuntos
Biópsia por Agulha/efeitos adversos , Endocardite Bacteriana/microbiologia , Valva Mitral/microbiologia , Próstata/patologia , Infecções Estafilocócicas/microbiologia , Staphylococcus lugdunensis/isolamento & purificação , Idoso , Dispneia/etiologia , Emergências , Endocardite Bacteriana/diagnóstico por imagem , Endocardite Bacteriana/patologia , Endocardite Bacteriana/cirurgia , Dermatoses do Pé/etiologia , Hemoptise/etiologia , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Valva Mitral/patologia , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/etiologia , Prolapso da Valva Mitral/complicações , Pele/microbiologia , Infecções Estafilocócicas/diagnóstico por imagem , Infecções Estafilocócicas/patologia , Infecções Estafilocócicas/cirurgia , Staphylococcus lugdunensis/patogenicidade , Ultrassonografia , Vasculite Leucocitoclástica Cutânea/etiologiaRESUMO
Maintaining mechanical circulatory support (MCS) device patients in a specified therapeutic range for anticoagulation remains challenging. Subtherapeutic international normalized ratios (INRs) occur frequently while on warfarin therapy. An effective anticoagulant bridge strategy may improve the care of these patients. This retrospective review of MCS patients with subtherapeutic INRs compared an intravenous unfractionated heparin (UFH) strategy with a subcutaneous enoxaparin or fondaparinux strategy. Native thromboelastography (n-TEG) was used to evaluate anticoagulant effect with coagulation index (CI) as the primary outcome measure. Enoxaparin 0.5 mg/kg subcutaneously (SC) every 12 hours or fondaparinux 2.5-5 mg SC daily were compared with an initial UFH rate of 5 units/kg/hr and titrated to stated n-TEG goal range. The anticoagulant groups UFH, enoxaparin, and fondaparinux were found to be statistically similar with regard to frequency in n-TEG goal range, above range (hypercoagulability), or below range (hypocoagulability). Clinical outcomes were similar among groups with three gastrointestinal bleeds in UFH, one in enoxaparin, and one in fondaparinux groups. Device thrombosis occurred in one UFH patient, while UFH and fondaparinux groups had one ischemic cerebrovascular accident event each. These strategies provided comparable n-TEG results and clinical outcomes when compared with intravenous UFH. Low-dose enoxaparin or fondaparinux may provide an alternative anticoagulant bridging option in MCS patients presenting with subtherapeutic INR.