Branko Calija

Primary PCI for acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura. A case report and review of the literature.

Background and Purpose:The occurrence of acute myocardial infarction (AMI) in patients with idiopathic thrombocytopenic purpura (ITP) is rare, especially when the platelet count is low. Since only few case reports have been published, there are no recommendations for the management of thrombocytopenic patients with AMI. The aim of the present study is to discuss different aspects of this challenging issue and to review limited data available in the literature.Case Study:An 80-year-old patient with ITP (platelet count 5 . 109/l) is presented who developed an AMI (ST segment elevation myocardial infarction) and was successfully treated by primary percutaneous coronary intervention (PCI).Conclusion:Considering the high bleeding risk in patients with ITP and AMI, careful balance between usual anticoagulation and antiplatelet therapy on the one hand, and efforts to raise platelet count on the other hand are needed.ZusammenfassungHintergrund und Fragestellung:Akute Myokardinfarkte (AMI) bei Patienten mit idiopathischer thrombozytopenischer Purpura (ITP, Morbus Werlhof) sind seltene Ereignisse. Da in der Literatur nur einige wenige Fälle beschrieben sind, existieren auch keine Therapieempfehlungen für diese Konstellation. In der vorliegenden Studie sollen unterschiedliche Aspekte dieser herausfordernden Situation diskutiert und die verfügbaren Daten aus der Literatur zusammenfassend beschrieben werden.Fallbericht:Geschildert wird der Fall eines 80-jährigen Patienten mit ITP (Thrombozytenzahl 5 . 109/l), der einen AMI (ST-Strecken-Hebungsinfarkt) erlitten hatte und mit primärer perkutaner Koronarintervention (PCI) erfolgreich behandelt wurde.Schlussfolgerung:Das hohe Blutungsrisiko bei Patienten mit ITP und AMI erfordert eine sorgfältige Balance zwischen Antikoagulation bzw. Plättchenhemmung einerseits und Anhebung der Thrombozytenzahl andererseits.

Primary PCI for Acute Myocardial Infarction in a Patient with Idiopathic Thrombocytopenic Purpura

Background and Purpose:The occurrence of acute myocardial infarction (AMI) in patients with idiopathic thrombocytopenic purpura (ITP) is rare, especially when the platelet count is low. Since only few case reports have been published, there are no recommendations for the management of thrombocytopenic patients with AMI. The aim of the present study is to discuss different aspects of this challenging issue and to review limited data available in the literature.Case Study:An 80-year-old patient with ITP (platelet count 5 . 109/l) is presented who developed an AMI (ST segment elevation myocardial infarction) and was successfully treated by primary percutaneous coronary intervention (PCI).Conclusion:Considering the high bleeding risk in patients with ITP and AMI, careful balance between usual anticoagulation and antiplatelet therapy on the one hand, and efforts to raise platelet count on the other hand are needed.ZusammenfassungHintergrund und Fragestellung:Akute Myokardinfarkte (AMI) bei Patienten mit idiopathischer thrombozytopenischer Purpura (ITP, Morbus Werlhof) sind seltene Ereignisse. Da in der Literatur nur einige wenige Fälle beschrieben sind, existieren auch keine Therapieempfehlungen für diese Konstellation. In der vorliegenden Studie sollen unterschiedliche Aspekte dieser herausfordernden Situation diskutiert und die verfügbaren Daten aus der Literatur zusammenfassend beschrieben werden.Fallbericht:Geschildert wird der Fall eines 80-jährigen Patienten mit ITP (Thrombozytenzahl 5 . 109/l), der einen AMI (ST-Strecken-Hebungsinfarkt) erlitten hatte und mit primärer perkutaner Koronarintervention (PCI) erfolgreich behandelt wurde.Schlussfolgerung:Das hohe Blutungsrisiko bei Patienten mit ITP und AMI erfordert eine sorgfältige Balance zwischen Antikoagulation bzw. Plättchenhemmung einerseits und Anhebung der Thrombozytenzahl andererseits.

The use of acute normovolemic hemodilution in patients undergoing cardiac surgery

Avoiding allogeneic blood transfusion during cardiac surgery and during the post-operative period is of great importance. Acute normovolemic hemodilution (ANH) is one of the options for blood salvage. We have prospectively analyzed 310 consecutive patients (pts) after different open heart procedures, operated on during April-May, 2000. ANH was possible in 226 pts (73%) with hemoglobin level over 125 g/l and hematocrit over 36%. Of those, one unit of blood was withdrawn in 128 pts (70%), while two to five units of blood were taken in 68 pts (30%). Total number of autologous blood units taken was 296, for the average of 1.31 units/pt. Predictors of increased intra- and post-operative blood loss were hematocrit (Hct) <39% (76% vs. 24%, p<0.001), age over 65 (p=0.028), female sex (p=0.006), CPB duration over 90 min (63% vs. 37%; p<0.001) and preoperative left ventricular ejection fraction (LVEF) <35% (63% vs. 37%; p<0.001). All pts with the above-mentioned characteristics were in need for allogeneic blood transfusion. During their hospital stay, 142 pts did not get allogeneic blood (142/310, 46%), and all were in the ANH group (142/226, 62%).

Clopidogrel High On-Treatment Platelet Reactivity in Patients with Carotid Artery Stenosis Undergoing Endarterectomy. A Pilot Study.

OBJECTIVES A considerable number of patients do not achieve an adequate response to clopidogrel. Our study aimed to evaluate genetic and non-genetic factors as possible risks for clopidogrel high on-treatment platelet reactivity (HTPR) in patients (n=112) with carotid artery stenosis undergoing endarterectomy (CEA). METHODS Using multiple-electrode impedance aggregometry (MEA) the antiplatelet effectiveness of clopidogrel was measured after 24 h, 7 and 30 days of clopidogrel treatment, which was introduced after elective CEA at a dose of 75 mg daily, for at least 30 days. RESULTS HTPR was observed among 25% patients after clopidogrel therapy for 30 days. Further analysis showed that 53.3% of patients carrying the CYP2C19*2 gene variant had clopidogrel-HTPR, while in the wild type group there were 14.6% (p<0.001). Multivariate logistic regression analysis identified the CYP2C19*2 variant allele (OR 4.384; 95% CI 1.296-14.833, p=0.017) and high total cholesterol level (OR 2.090; 95% CI 1.263-3.459, p=0.004) as the only independent risk factors for clopidogrel-HTPR. CONCLUSION The CYP2C19*2 gene variant and high total cholesterol level were major factors for clopidogrel- HTPR in patients with carotid artery stenosis undergoing CEA.

Experience with IgM-enriched immunoglobulins as adjuvant therapy in septic patient after redo cardiac surgery

Infective endocarditis after combined mitral valve repair and coronary artery bypass surgery, multi-organ failure and sepsis, were treated with mitral valve replacement, antibiotics and adjunctive therapy. Sepsis caused by Gramnegative bacteria, was identified based on the grave clinical status, hemodynamic findings and high levels of proinflammatory cytokines. On the day of the redo surgery, the APACHE II and SOFA scores were 26 and 14, respectively. The IgM-enriched immunoglobulin Pentaglobin® was administered on the first postoperative day after redo procedure. The cardiac index improved from 1.9 L/m2 to 3.7 L/m2 on the 1st postoperative day, accompanied with increasing values of mixed venous oxygen saturation from 59.3% to 77%, while systemic vascular resistance 887 dyn·s/cm5 was maintained by vasopressor agent. On the 4th postoperative day the inotropes and pressors ceased. The acute physiology and chronic health evaluation (APACHE II) score and sequential organ failure assessment (SOFA) score decreased to 10 and 2, respectively. The prompt improvement in patient’s general clinical condition, stabilised hemodynamic parameters, balanced perfusion and oxygen pattern, accompanied by notable reduction of pro-inflammatory cytokine expression, were the outcome of the presented therapeutic approach.

Recombinant factor VII (NovoSeven) in intraoperative blood saving during neurosurgical treatment of the brain arteriovenous malformation

BACKGROUND Cerebral arteriovenous (AV) malformation causes, due to the increased blood flow through a malformation, a massive intraoperative bleeding complicating, so, surgical treatment. The use of intraoperative blood saving apparatus during surgery and a recombinant factor VII-a (NovoSeven) significantly reduce complications during surgical treatment. CASE REPORT We reported a case of surgical treatment of the patient with AV malformation of IV stage according to the Spetzler-Martin scale, in the brain. Due to a possible heavy bleeding we used a apparatus for intrasurgical blood recovery, Cell Saver, Sequestra 1 000, Medtronic, U.S.A., and recombinant human factor VIIa (rFVIIa--NovoSeven, NovoNordisk, Denmark) to control bleeding and restore an adequate hemostasis. CONCLUSION The use of an apparatus for intraoperative blood saving, as well as the NovoSeven preparation in the management of AV malformation of IV stage, showed to be successful.

Scoring system to predict early carotid restenosis after eversion endarterectomy by analysis of inflammatory markers

Background: Inflammation is one of the mechanisms that leads to carotid restenosis (CR). The aim of this study was to examine the influence of increased values of inflammation markers (high‐sensitivity C‐reactive protein [hs‐CRP], C3 complement, and fibrinogen) on CR development after eversion carotid endarterectomy (CEA). Methods: A consecutive 300 patients were included in the study, in which eversion CEA was performed between March 1 and August 1, 2010. Demographic data, atherosclerosis risk factors, comorbidities, and ultrasound plaque characteristics were listed in relation to potential risk factors for CR. Serum concentrations of hs‐CRP, fibrinogen, and C3 complement were taken just before surgery (6 hours); 48 hours after CEA; and during regular checkups at 1 month, 6 months, 1 year, and 2 years. An “inflammatory score” was also created, which consisted of six predictive values of inflammatory markers (hs‐CRP just before and just after CEA, fibrinogen just before and just after CEA, and C3 complement just before and just after CEA) with a maximum score of 6 and a minimum score of 0. At every follow‐up visit to the outpatient clinic, ultrasound assessment of the carotid artery for restenosis was done. Results: Our results showed an increased risk of early CR within 1 year in patients with increased hs‐CRP before CEA (6 hours) and increased fibrinogen 48 hours after surgery and in patients not taking aspirin after CEA. Sex was determined to be an independent predictor of CR, with female patients having a higher risk (P = .002). Male patients taking aspirin with an inflammatory score >2 had an increased risk for restenosis compared with male patients with inflammatory score <2. Not taking aspirin after CEA and fibrinogen (48 hours) were the strongest predictors, and the Fisher equation incorporating these predictors was used to predict CR. A computer program was created to calculate whether the patient was at high or low risk for CR by selecting whether the patient was taking aspirin (yes or no) and whether fibrinogen was increased 48 hours after CEA (yes or no) and to display the recommended therapeutic algorithm consisting of aspirin, clopidogrel, cilostazol, and statins. Conclusions: Increased hs‐CRP before CEA, increased fibrinogen 48 hours after CEA, and not taking aspirin were the main predictors of early CR. With the clinical implementation of the Fisher equation, it is possible to identify patients at high risk for early CR and to apply an aggressive therapeutic algorithm, finally leading to a decreased CR rate.

Influence of Cyp2c19*2 Gene Variant on Therapeutic Response During Clopidogrel Treatment in Patients with Carotid Artery Stenosis/ Uticaj cyp2c19*2 varijante gena na terapijski odgovor u toku primene klopidogrela kod bolesnika sa stenozom karotidne arterije

Summary Background: Despite the proven clinical effect of oral antiplatelet drugs, a considerable number of patients do not have an adequate response to clopidogrel. The aim of our study was to determine the influence of CYP2C19*2 loss-of-function variant allele on clopidogrel responsiveness in patients with carotid artery stenosis. Methods: One hundred and twelve patients with carotid artery stenosis undergoing endarterectomy were included in this one-year prospective study. All of them received clopidogrel (75 mg daily) for at least 30 days after the intervention. They were followed from the moment of hospital admission. CYP2C19*2 genotyping was performed by TaqMan Assay. The influence of CYP2C19*2 variant allele on clopidogrel platelet reactivity was determined using multiple-electrode aggregometry (MEA). Results: Genotyping results showed that 82 (73.2%) patients were homozygous for wild type, 29 (25.9%) were heterozygous for the CYP2C19*2 allele and 1 (0.9%) was CYP2C19*2 homozygous. After 24 hours, among those with the wild type 29.3% were clopidogrel responders, and in those with the CYP2C19*2 alleles 10%. In the wild type group, 74.4% were clopidogrel responders after 7 days of taking the drug; 82.9% after 30 days of clopidogrel introduction, respectively. In patients with the CYP2C19*2 alleles the number of responders increased up to 46.7% after 7 days; 53.3% after 30 days of taking the drug, respectively. The risk for being a low-responder is higher for the patients heterozygous for the CYP2C19*2 allele vs. wildtype (OR 4.250, 95% CI 1.695-10.658, P<0.01). Conclusions: The CYP2C19*2 loss-of-function variant allele has significant influence on clopidogrel response in patients with carotid artery stenosis undergoing endarterectomy. Kratok sadržaj Uvod: I pored dokazanog kliničkog efekta oralne antiagre- gacijske terapije, značajan broj pacijenata nema adekvatan odgovor na primenjeni klopidogrel. Cilj naše studije je bio da se utvrdi uticaj prisutne CYP2C19*2 varijante gena na terapijski odgovor u toku primene klopidogrela kod pacijenata sa stenozom karotidne arterije. Metode: U jednogodišnju prospektivnu studiju uključeno je 112 pacijenata sa stenozom karotidne arterije kod kojih je izvršena endarterektomija. Posle operativnog zahvata, pa- cijenti su primali 75 mg dnevno klopidogrela u trajanju od najmanje mesec dana. Svi ispitanici su praćeni od momenta prijema. Za CYP2C19 genotipizaciju korišćen je TaqMan test. Uticaj CYP2C19*2 alela na trombocitnu reaktivnost ispitivan je primenom multiple-electrode aggregometry (MEA). Rezultati: Rezultati genotipizacije su pokazali da su 82 (73,2%) ispitanika homozigoti za wild-type, 29 (25,9%) heterozigoti za CYP2C19*2 alel, dok je 1 (0,9%) bio homo- zigotza CYP2C19*2. Nakon 24 sata, u grupi sa wild-type genotipom 29,3% ispitanika dali su odgovor na klopidogrel, a u grupi sa CYP2C19*2 varijantom gena 10% ispitanika. U grupi sa wild-type genotipom, 74,4% ispitanika su imali terapijski odgovor nakon 7 dana, odnosno 82,9% nakon 30 dana od primene klopidogrela. U grupi sa CYP2C19*2 alelom broj ispitanika sa terapijskim odgovorom raste do 46,7% nakon 7 dana, odnosno do 53,3% nakon 30 dana od primene klopidogrela. Rizik za slab odgovor je veći kod nosilaca CYP2C19*2 alela u odnosu na nenosioce (wild-type) (OR 4,250, 95% Cl 1.695-10.658, P<0,01). Zaključak: CYP2C19*2 varijanta gena značajno utiče na terapijski odgovor u toku primene klopidogrela kod bolesnika sa stenozom karotidne arterije kod kojih je izvršena endarterektomija.

Primary PCI for Acute Myocardial Infarction in a Patient with Idiopathic Thrombocytopenic Purpura@@@Primäre PCI wegen akuten Myokardinfarkts bei einem Patienten mit idiopathischer thrombozytopenischer Purpura. Fallbericht und Literaturübersicht: A Case Report and Review of the Literature

Background and Purpose:The occurrence of acute myocardial infarction (AMI) in patients with idiopathic thrombocytopenic purpura (ITP) is rare, especially when the platelet count is low. Since only few case reports have been published, there are no recommendations for the management of thrombocytopenic patients with AMI. The aim of the present study is to discuss different aspects of this challenging issue and to review limited data available in the literature.Case Study:An 80-year-old patient with ITP (platelet count 5 . 109/l) is presented who developed an AMI (ST segment elevation myocardial infarction) and was successfully treated by primary percutaneous coronary intervention (PCI).Conclusion:Considering the high bleeding risk in patients with ITP and AMI, careful balance between usual anticoagulation and antiplatelet therapy on the one hand, and efforts to raise platelet count on the other hand are needed.ZusammenfassungHintergrund und Fragestellung:Akute Myokardinfarkte (AMI) bei Patienten mit idiopathischer thrombozytopenischer Purpura (ITP, Morbus Werlhof) sind seltene Ereignisse. Da in der Literatur nur einige wenige Fälle beschrieben sind, existieren auch keine Therapieempfehlungen für diese Konstellation. In der vorliegenden Studie sollen unterschiedliche Aspekte dieser herausfordernden Situation diskutiert und die verfügbaren Daten aus der Literatur zusammenfassend beschrieben werden.Fallbericht:Geschildert wird der Fall eines 80-jährigen Patienten mit ITP (Thrombozytenzahl 5 . 109/l), der einen AMI (ST-Strecken-Hebungsinfarkt) erlitten hatte und mit primärer perkutaner Koronarintervention (PCI) erfolgreich behandelt wurde.Schlussfolgerung:Das hohe Blutungsrisiko bei Patienten mit ITP und AMI erfordert eine sorgfältige Balance zwischen Antikoagulation bzw. Plättchenhemmung einerseits und Anhebung der Thrombozytenzahl andererseits.