title: Left ventricle thrombus after tranexamic acid for spine surgery in an HIV-positive patient.
abstract: BACKGROUND
  Our case highlights the underappreciated thrombotic risks of tranexamic acid (TXA) use in non-cardiac surgery and emphasizes the need to elucidate these risks with appropriate clinical trials.
  
  
  OBJECTIVE
  The use of TXA in non-cardiac surgery has significantly expanded in the past 5 years, especially after the 2010 publication of the CRASH-2 Trial. We submit a case with the intent to highlight the thrombotic risk of TXA use during non-cardiac surgery and discuss the need for careful risk stratification before the use of TXA in this context.
  
  
  METHODS
  A 66-year-old man with long-standing HIV infection, hypertension, and no history of coronary artery disease (CAD) presented for revision spinal fusion surgery with the use of TXA is presented.
  
  
  METHODS
  To limit perioperative blood loss, the case patient received TXA intraoperatively. His operative course was uneventful.
  
  
  RESULTS
  During the first 12 hours postoperatively the patient was noted to have persistent tachycardia and ST-elevation on electrocardiogram. Echocardiography showed a new apical wall motion abnormality and a left ventricle thrombus; cardiac catheterization confirmed two-vessel CAD, treated with a bare-metal stent and anticoagulation.
  
  
  CONCLUSIONS
  The thrombotic risks of TXA use in non-cardiac surgery have yet to be adequately studied in clinical trials. Hence, TXA use in this context is still an area of uncertainty, and its thrombogenic risks have yet to be studied as a primary outcome in any large prospective trial to date. Patients with any hypercoagulable risk factors, including HIV infection or any prior thrombotic history in which TXA use is being considered, should prompt a discussion among the perioperative physicians involved.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA. Electronic address: ngerstein@gmail.com.
authors.forename: Neal Stuart
authors.initials: NS
authors.lastname: Gerstein
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA.
authors.forename: Janet Kathryn
authors.initials: JK
authors.lastname: Brierley
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10 6000, 2211 Lomas Blvd NE, Albuquerque, New Mexico 87106, USA.
authors.forename: Matthew Douglas
authors.initials: MD
authors.lastname: Culling
mesh_terms: D000368:Aged; D000933:Antifibrinolytic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D015658:HIV Infections / Q000150:complications; D006331:Heart Diseases / Q000139:chemically induced*; D006352:Heart Ventricles / Q000473:pathology; D006801:Humans; D008297:Male; D019635:Neurosurgical Procedures / Q000009:adverse effects; D013131:Spine / Q000601:surgery*; D013927:Thrombosis / Q000139:chemically induced*; D014148:Tranexamic Acid / Q000009:adverse effects* / Q000627:therapeutic use
chemical_list: D000933:Antifibrinolytic Agents; D014148:Tranexamic Acid
keywords: HIV; Hypercoagulable; Left ventricle thrombus; Spine surgery; Tranexamic acid