The management of patients anticoagulated with warfarin and referred for coronary angiography presents a substantial challenge to the physician who must minimize risks of periprocedural hemorrhage and thromboembolism. The aim of this study was to evaluate the feasibility and safety of performing diagnostic coronary angiography and percutaneous coronary intervention during uninterrupted warfarin therapy. Patients treated with warfarin were prospectively identified and enrolled in the study. Nineteen diagnostic cardiac catheterizations and six percutaneous coronary interventions were performed in 23 patients. The mean international normalized ratio was 2.4 +/- 0.5 (range, 1.8-3.5). Hemostasis was achieved with AngioSeal following 21 procedures and with Perclose following 4 procedures. No patient experienced a predefined endpoint. Specifically, no patient experienced procedure-related myocardial infarction, major or minor bleeding. We conclude that cardiac catheterization and percutaneous coronary intervention may be considered in the setting of uninterrupted warfarin therapy.
Antibody‐mediated rejection (AMR) in heart transplants in the absence of anti‐HLA donor‐specific antibody (DSA) is not well studied or documented. This case reviews hyperacute fulminant graft dysfunction suspected to be mediated by non‐HLA antibodies. After cross clamp removal, the patient developed severe pulmonary edema, profound coagulopathy, and biventricular failure. The patient's presumed AMR, cardiogenic shock, and coagulopathy were treated with extracorporeal membrane oxygenation (ECMO), plasmapheresis, intravenous immunoglobulin (IVIG), multiple blood products, and prothrombin complex concentrate. The recipient was 0% panel‐reactive antibody (PRA), ABO, and crossmatch compatible. Intraoperative biopsy sample revealed a thrombotic process suggestive of a coagulation pathway activated by AMR; however, no C4d deposition was detected. Postmortem biopsies also suggested AMR. Retrospective testing of the patient's pretransplant serum revealed strong antiangiotensin II type 1 receptor (AT1R) antibodies and a strongly positive endothelial cell crossmatch. Anti‐AT1R antibodies are known to be AT1 receptor agonists and may trigger inflammation and activate the extrinsic coagulation pathway. Given the potential effects of signaling through the AT1R, the patient's preexisting anti‐AT1R antibodies and procoagulant therapy may have adversely affected the patient's clinical course.
Telemetry is done in a variety of settings with different levels of sophistication. The American College of Cardiology has made suggestions for telemetry monitoring but these are not in place in many smaller community hospitals that do telemetry monitoring. The objective of this study was to compare prospectively telemetry without a dedicated monitor watcher or full disclosure to results obtained on full disclosure. Patients included were admitted to a single community hospital with an indication for telemetry as judged by their primary physician. Telemetry results reported by the hospital staff were compared to over-read of full disclosure traces by an academic cardiology service and the patient was used as his own control. Significant rhythm disturbances including pauses of 2 seconds or greater and short runs of ventricular and supraventricular tachycardia were frequently missed when a dedicated monitor watcher and full disclosure were not in use. When a dedicated monitor watcher and full disclosure are not in use, telemetry results should be accepted with caution and attempts should be made to improve monitoring.
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