Summary. Background: Mitral valve regurgitation is associated with an acquired hemostatic defect. Objective: We sought to assess the prevalence and severity of acquired von Willebrand syndrome in patients with native valve mitral regurgitation (MR). Patients/Methods: Fifty-three patients were prospectively observed with bleeding questionnaires and laboratory tests when undergoing an echocardiographic assessment of MR. In patients referred for mitral valve surgery, testing was repeated postoperatively. , respectively (all P < 0.001). Nine patients reported clinically significant bleeding, and seven had intestinal angiodysplasia and transfusion-dependent gastrointestinal bleeding (Heyde syndrome), with the median number of transfusions required being 20 . In patients who underwent mitral valve repair (n = 13) or replacement (n = 7), all measures of VWF function reported above improved significantly. Conclusion: The high-shear environment of moderate to severe MR is sufficient to produce prevalent perturbations in VWF activity.Acquired von Willebrand syndrome may occur in this setting, and appears to be reversible with mitral valve surgery.

We correlated von Willebrand factor activity indices and brain natriuretic peptide (BNP) with measures of aortic stenosis (AS) severity, bleeding, symptoms, and freedom from death or aortic valve replacement. Patients with AS (n=66 [16 mild, 20 moderate, 30 severe]) and aortic valve replacement (n=21) were assessed with VWF antigen (VWF:Ag), VWF latex agglutination immunoturbidic activity (VWF:Ltx), platelet function analyzer collagen plus adenosine diphosphate (PFA-CADP), VWF multimer ratio (VWF:mult ratio), and BNP level after echocardiography. In AS patients, mean gradient correlated with BNP (Spearman r=0.29, P=.02), VWF:Ltx/VWF:Ag (r=–0.41, P<.001), PFA-CADP (r=0.49, P<.001), and VWF:mult ratio (r=–0.76, P<.001). The area under the curve (95% CI) for detection of severe AS was 0.62 (0.48-0.77) by elevated BNP, 0.81 (0.69-0.92) by PFA-CADP closure time, 0.69 (0.55-0.82) by VWF:Ltx/VWF:Ag ratio, and 0.86 (0.76-0.95) by VWF:mult ratio. For VWF:mult ratio, a threshold of 0.15 yielded sensitivity and specificity for severe AS of 77% and positive predictive value of 74%. Bleeding (in 14%) was associated with prolonged PFA-CADP and reduced VWF:Ltx/VWF:Ag. Symptoms were associated with elevated BNP and low Duke Activity Status Index score. In 66 AS patients, freedom from death (n=4) or aortic valve replacement (n=22) was associated with PFA-CADP (P=.003), VWF high molecular weight multimers (HMWM) (P=.009), and VWF:Ltx/VWF:Ag (P<.001), but not BNP (P=.32). In severe AS vs aortic valve replacement, PFA-CADP and VWF:mult ratio differed (P<.001), but BNP and VWF:Ltx/VWF:Ag did not. In conclusion, VWF activity indices are associated with AS severity and bleeding, and predictive of cardiovascular outcome.

Ticagrelor offers an effective alternative to clopidogrel non-responders. All of our patients showed immediate platelet inhibition after a loading dose of 180 mg of ticagrelor, with no adverse effects. The cost of medication, patient compliance (twice a day doses), and reversible inhibition should be taken into consideration when using ticagrelor.

In our cohort, bleeding-related complications 48 h and 1 week post-ablation were similar for warfarin and dabigatran. Dabigatran is associated with more intraprocedural variability in ACT than warfarin.

Objective: To reduce diagnostic blood loss by using small volume tubes for routine laboratory testing throughout the hospital, as blood loss from laboratory testing can be substantial for patients and may lead to hospital-acquired anemia. Patients and Methods: Diagnostic blood loss was evaluated in hospitalized patients between April 1, 2017, and June 1, 2018. The preintervention, during intervention, and postintervention mean diagnostic blood loss per hospitalized patient was compared across the floors and for each type of tube for hematology, basic metabolic panel, and coagulation tests. Mean hemoglobin levels, blood transfusions per hospitalized patient, and percent redraws were also compared. Results: The total volume of blood drawn for all the 3 tests decreased across each implementation phase; however, only patients admitted to the transplant and critical care (T/CC) units had increased hemoglobin levels. In addition, there was a significant reduction in transfusions across implementation phases. The incidence risk ratio for transfusion reduced even more in patients admitted to the T/CC units. Finally, there was no significant difference in the overall percent redraws across all the units. Conclusion: The use of small volume tubes in exchange for standard sized tubes markedly decreased diagnostic blood loss by 25.7% in all the units and 22.9% in the T/CC units. Also, the number of transfusions decreased across units, with the greatest decrease in the T/CC units. An increase in mean hemoglobin levels was observed specifically in patients admitted to the T/CC units, with no corresponding change in percent redraws across all the units.

Serum free light chain assay is a recently available test for diagnosis and monitoring of patients with plasma cell dyscrasias. In particular, this test is especially useful in patients that were previously difficult to follow with traditional laboratory methods. These patients include non-secretory multiple myeloma, amyloidosis and light chain deposition disease. In addition other uses for the test include monitoring response to treatment and earlier detection of relapse in all patients with plasma cell dyscrasias. Potential uses include assessing progression of patients with monoclonal gammopathy of undetermined significance, smoldering multiple myeloma, solitary bone plasmacytoma and extramedullary plasmacytoma to multiple meyloma. Analytical considerations for the assay are also discussed.

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