Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-06-14T18:35:57Z No. of bitstreams: 1 HiranReisSousa.pdf: 2489901 bytes, checksum: 8a82807f0600af87559439a496bd0d2a (MD5) / Made available in DSpace on 2017-06-14T18:35:57Z (GMT). No. of bitstreams: 1 HiranReisSousa.pdf: 2489901 bytes, checksum: 8a82807f0600af87559439a496bd0d2a (MD5) Previous issue date: 2016-12-06 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ) / Fundação de Amparo à Pesquisa e ao Desenvolvimento Científico e Tecnológico do Maranhão (FAPEMA) / Recent researches have emphasized the importance of redox mechanisms for platelet function modulation. The platelet surface contains a large variety of integrin receptors and other molecules presenting functional thiol groups in their structures, which are potential targets for redox regulation. Among these various thiol-containing proteins, integrin αIIbβ3 stands out for being the convergence path of platelet activation induced by various agonists. Activation of αIIbβ3 integrin is catalyzed by protein disulfide isomerase (PDI) through an essential conformational change leading to the exposure of fibrinogen-binding site. Thus, PDI has been shown to be an important target for the development of antiplatelet drugs. In recent years, many studies have described substances from plan (DE A. PAES et al., 2011), as well as synthetics that are capable of inhibiting PDI. In a previous study of our research group has shown that the synthetic peptide CxxC, which contains the redox motif of PDI in its original sequence CGHC, inhibited reductase activity of this enzyme, effect not observed with AxxA peptide, whose cysteines were replaced with alanine and Scr peptide, which contains the same aminoacids from CxxC peptide, but under random sequence. It has been also demonstrated that CxxC peptide was the only to reduce by 30% ADP-induced aggregation (5μM) in platelet rich plasma, an effect apparently mediated by the association of CxxC and PDI at platelet surface. Thus, in this work, we further assessed the effects of CxxC and its control peptides on platelet aggregation. Washed human platelets were incubated with CxxC peptide at concentrations of 3, 6 and 10 μM, resulting in a dose-dependent inhibition of maximum aggregation activated by thrombin (0.02 U/mL) at 25, 60 and 74%, respectively with IC50 of 6.13 ± 1.09 μM. The presence of control peptides did not produce any inhibitory effect. CxxC peptide also reduced the activation of αIIbβ3 integrin at platelet surface, but did not affect the expression of the markers CD 62-P and CD 63. Control peptides did not alter the expression of these markers. Analysis by mass spectrometry of the interaction of recombinant human PDI with the peptide showed that only CxxC peptide associated with the redox Cys400 of a’ motif of PDI, which has been considered essential for platelet aggregation. Together, these results demonstrate that CxxC peptide reduces platelet aggregation by association with PDI and can be further used as a model for the development of new antithrombotic drugs. / Investigações recentes têm enfatizado a importância de mecanismos redox na modulação da função plaquetária. A superfície da plaqueta contém grande variedade de integrinas e outras moléculas receptoras que possuem tióis funcionais em sua estrutura, os quais são alvos potenciais de regulação redox. Dentre estas várias proteínas tiólicas, a integrina αIIbβ3 destaca-se por ser a via de convergência da ativação plaquetária induzida por diversos agonistas. A ativação da integrina αIIbβ3 é catalisada pela proteína dissulfeto isomerase (PDI), essencial à mudança de conformação que leva à exposição do sitio de ligação ao fibrinogênio. Sendo assim, a PDI tem se mostrado como um alvo importante para o desenvolvimento de fármacos reguladores da agregação plaquetária. Nos últimos anos, diversos estudos têm descrito substâncias de origem vegetal, animal e sintéticas que são capazes de inibir a PDI. Em trabalho do nosso grupo de pesquisa (DE A. PAES et al., 2011), demonstrou que o peptídeo sintético CxxC, o qual contém o motivo redox da PDI na sua sequência original CGHC, inibiu a atividade redutase desta enzima; efeito não observado com os peptídeos AxxA, que possui as cisteínas substituídas por alanina e Scr, peptídeo controle contendo os mesmos aminoácidos do peptídeo CxxC, porém com sequência aleatória sem formação de ditiol. Demonstrou-se, também, que apenas o peptídeo CxxC reduziu em 30% a agregação induzida por ADP (5M) em plasma rico em plaquetas, efeito aparentemente mediado pela associação do CxxC com a PDI na superfície plaquetária. Sendo assim, neste trabalho continuamos a avaliação dos efeitos do peptídeo CxxC e seus controles sobre a agregação plaquetária. Para tanto, incubamos lavado de plaquetas humanas com o peptídeo CxxC nas concentrações de 3, 6 e 10 μM, resultando em inibição concentração-dependente da agregação ativada por trombina (0,02 U/mL) em 25, 60 e 74 %, respectivamente, com IC50 de 6,13 ± 1,09 μM. A presença dos peptídeos controle não produziu quaisquer efeitos inibitórios. O peptídeo CxxC reduziu a ativação da integrina αIIbβ3 na superfície da plaqueta, porém não impactou a expressão dos antígenos CD 62-P e CD 63. Os peptídeos controle não alteraram a expressão desses marcadores. A análise por espectrometria de massas da interação da PDI recombinante humana com os peptídeos, mostrou que apenas o peptídeo CxxC associa-se com a Cys400 do motivo redox a’ da hPDI, o qual tem sido considerado fundamental para a agregação plaquetária. Em conjunto, estes resultados demonstram que o peptídeo CxxC reduz a agregação plaquetária via associação com a PDI, podendo ser empregado como modelo para o desenvolvimento de fármacos novos antitrombogênicos.

Objective: A systematic review and meta-analysis was performed to evaluate the safety and efficacy of drug-eluting stents (DES) vs bare-metal stents (BMS) in atrial fibrillation (AF) patients. Methods: We systematically searched 5 engines until May 2019 for cohort studies and randomized controlled trials (RCTs). Primary outcomes were major bleeding and major adverse cardiac events (MACE) including cardiac death, myocardial infarction, target vessel revascularization (TVR) or stent thrombosis. Effects of inverse variance random meta-analyses were described with relative risks (RR) and their 95% confidence intervals (CI). We also stratified analyses by type (triple [TAT] vs dual [DAT]) and duration (short-vs long-term) of antithrombotic therapy. Results: Ten studies (3 RCTs; 7 cohorts) including 10,353 patients (DES: 59.6%) were identified. DES did not show higher risk of major bleeding than BMS (5.6% vs 6.9%, RR 1.07; 95%CI, 0.89–1.28, p = 0.47; I2 = 0%) or MACE (12% vs 13.6%; RR 0.96; 95%CI 0.81–1.13, p = 0.60; I2 = 44%). Although, DES almost decreased TVR risk (6.4% vs 8.4%, RR 0.78; 95%CI, 0.61–1.01, p = 0.06; I2 = 15%). Stratified analyses by type and duration of antithrombotic therapy showed no differences in major bleeding or MACE between both types of stents. In DES, long-term TAT showed higher major bleeding risk than long-term DAT (7.7% vs 4.7%, RR 1.48, 95%CI 1.08–2.03, p = 0.01; I2 = 12%). For both types of stents, MACE risk was similar between TAT and DAT. Conclusions: In patients with AF undergoing PCI, DES had similar rate of major bleeding and MACE than BMS. DAT seems to be a safer antithrombotic therapy compared with TAT. / Janssen Pharmaceuticals / Revisión por pares

Les Thrombopénies Induites par l’Héparine (TIH) sont une complication sévère des traitements par l’héparine dues à des IgG qui ciblent le facteur plaquettaire 4 modifié par l’héparine (FP4/H) et induisent une activation cellulaire via FcγRIIA, conduisant à des complications thrombotiques. Nous avons caractérisé 5B9, IgG1 monoclonale chimérique anti-FP4/H mimant parfaitement les anticorps de TIH et qui est donc un excellent outil pour étudier la physiopathologie des TIH. La pathogénicité des anticorps (Ac) de TIH implique leur fixation aux FcγR. Nous avons montré que le clivage de la région charnière des IgG de TIH par IdeS inhibe ces interactions IgG-FcγR et supprime la pathogénicité des Ac. Nous avons aussi construit un Antibody-Drug Conjugate (ADC) antithrombotique, en bioconjuguant le tirofiban (inhibiteur de l’agrégation plaquettaire) et 5B9 déglycosylé grâce à un linker clivable par la thrombine, protéase générée en excès lors d’une TIH. / Heparin Induced Thrombocytopenia (HIT) is a rare but severe complication of heparin treatments. HIT is due to IgG antibodies specific to platelet factor 4 modified by heparin (PF4/H), which activate blood cells, (especially platelets) after binding to FcγRIIA, this process explaining frequent thrombotic complications. We characterized 5B9, a chimeric IgG1 targeting PF4/H and which fully mimics human HIT antibodies. Therefore, 5B9 is a perfect tool for studying the physiopathology of HIT. IgG antibodies to PF4/H are pathogenic by interacting with FcγR. In this regard, we showed that cleavage by IdeS, a bacterial protease, of the hinge of anti-PF4/H IgG, fully suppressed their pathogenicity. Furthermore, we designed an antithrombotic Antibody-Drug Conjugate that combined tirofiban, a GPIIbIIIa inhibitor with deglycosylated 5B9 using a thrombin cleavable linker.

Coronary artery disease (CAD) is the leading cause of mortality worldwide and atrial fibrillation (AF) is a prevalent arrhythmia associated with increased risk of mortality and morbidity. Despite improved outcome in both diseases, there is a need to further describe the prevalence, outcome and management of CAD in patients with concomitant AF. AF was a common finding among patients with MI, with 16% having new-onset, paroxysmal or chronic AF. Patients post-MI with concomitant AF, regardless of subtype, were at increased risk of composite cardiovascular outcome of mortality, MI or ischemic stroke, including mortality and ischemic stroke alone. No major difference in outcome was observed between AF subtypes. At discharge, an oral anticoagulant was prescribed to 27% of the patients with MI and AF undergoing percutaneous coronary intervention (PCI). Aspirin or clopidogrel plus warfarin versus dual antiplatelet therapy with aspirin plus clopidogrel were associated with similar 0-90-day and lower 91-365-day risk of cardiovascular outcome, without increased risk of major bleeding events. Triple therapy with aspirin, clopidogrel plus warfarin versus dual antiplatelet therapy was associated with non-significant lower risk of cardiovascular outcome, but with increased risk of bleeding events. Treatment with renin-angiotensin system (RAS) inhibitors post-MI was associated with lower risk of all-cause and cardiovascular mortality in patients with and without congestive heart failure and/or AF. However, RAS inhibition in patients without AF was not associated with lower risk of new-onset AF. Approximately 1 in 3 patients undergoing isolated coronary artery bypass grafting (CABG) had pre- or postoperative AF. Patients with AF, regardless of subtype, were at higher risk of all-cause mortality, cardiovascular mortality and congestive heart failure. Furthermore, postoperative AF was associated with higher risk of recurrent AF. In conclusion, AF was a common finding in the setting of MI and CABG. AF, irrespectively if in the setting of MI or CABG was associated with higher risk of ischemic events and mortality. Also, postoperative AF was associated with recurrent AF. Oral anticoagulants post-MI and PCI in patients with AF was underutilized, however, optimal antithrombotic therapy is still unknown. RAS inhibition post-MI seems beneficial, however, it was not associated with lower incidence of new-onset AF.

Made available in DSpace on 2014-12-17T14:03:38Z (GMT). No. of bitstreams: 1 MoniqueGCFA_DISSERT_PARCIAL.pdf: 1765775 bytes, checksum: 3815c2c3560cb6ce59df27ea29b474ca (MD5) Previous issue date: 2011-07-18 / Conselho Nacional de Desenvolvimento Cient?fico e Tecnol?gico / Marine algae are one of the major sources of biologic compounds. In extracellular matrix of these organisms there are sulfated polysaccharides that functions as structural components and provides protection against dehydration. The fraction 1.0 (F1.0) rich in sulfated galactans obtained from red seaweed Hypnea musciformis was physicochemical characterized and evaluated for pharmacologic activity through antioxidant activity, cytotoxic action on erythrocytes, anticoagulant, stimulatory action under antithrombotic heparan sulfate synthesis and their effects on cell proliferation and cycle cell progression. The main components of F1.0 were carbohydrates (49.70 ? 0.10%) and sulfate (44.59 ? 0.015%), presenting phenolic compounds (4.79 ? 0.016%) and low protein contamination (0.92 ? 0.001%). Fraction 1.0 showed polidisperse profile and signs in infrared analysis in 1262, 1074 and 930, 900 and 850 attributed to sulfate esters S=O bond, presence of a 3,6- anidrogalactose C-O bond, non-sulfated ?-D-galactose and a C-O-SO4 bond in galactose C4, respectively. The fraction rich in sulfated galactans exhibited strong antioxidant action under lipid peroxidation assay with IC50 of 0.003 mg/mL. Besides the inhibition of hemolysis induced by H2O2 in erythrocytes treated with F1.0, this fraction did not promote significant cytotoxity under erythrocytes membranes. F1.0 exhibited low anticoagulant activity causing moderate direct inhibition of enzimatic activity of thrombin. This fraction promoted stimulation around of 4.6 times on this synthesis of heparan sulfate (HS) by rabbit aortic endothelial cells (RAEC) in culture when was compared with non treated cells. The fraction of this algae displayed antiproliferative action under RAEC cells causing incresing on cell number on S fase, blocking the cycle cell progression. Thus F1.0 presented cytostatic and no cytotoxic action under this cell lineage. These results suggest that F1.0 from H. musciformis have antioxidant potential which is a great effect for a compound used as food and in food industry which could be an alternative to food industry to prevent quality decay of lipid containing food due to lipid peroxidation. These polysaccharides prevent the lipid peroxidation once the fraction in study exhibited strong inhibitory action of this process. Furthermore that F1.0 present strong antithrombotic action promoting the stimulation of antithrombotic HS synthesis by endothelial cells, being important for thrombosis preventing, by its inhibitory action under reactive oxygen species (ROS) in some in vitro methods, being involved in promotion of hypercoagulability state. / Algas marinhas s?o uma das principais fontes de compostos biologicamente ativos. Na matriz extracelular desses organismos existem os polissacar?deos sulfatados que funcionam como componente estrutural prevenindo-a contra desidrata??o. A fra??o 1,0 (F1,0) rica em galactanas sulfatadas obtida da alga vermelha Hypnea musciformis foi caracterizada fisicoquimicamente e avaliada quanto a atividade farmacol?gica por meio de ensaios de atividade antioxidante, a??o citot?xica sobre hem?cias, atividade anticoagulante, a??o estimulat?ria sobre a s?ntese de heparam sulfato antitromb?tico e seus efeitos na prolifera??o e progress?o do ciclo celular. Os principais componentes da F1,0 foram carboidratos (49,70 ? 0,10%) e sulfato (44,59 ? 0,015%), apresentando compostos fen?licos (4,79 ? 0,016%) e baixa contamina??o prot?ica (0,92 ? 0,001%). F1,0 mostrou perfil polidisperso e sinais na an?lise de infravermelho em 1262, 1074 e 930, 900 e 850 cm-1 atribu?dos a liga??es S=O de ?steres de sulfato, presen?a de liga??o C-O de 3,6-anidrogalactose, ?-D-galactose n?o sulfatada e liga??o C-O-SO4 no C4 da galactose, respectivamente. A fra??o rica em galactanas sulfatadas exibiu forte a??o antioxidante sobre o ensaio de peroxida??o lip?dica com IC50 de 0,003 mg/mL. Al?m da alta inibi??o da hem?lise induzida por H2O2 em hem?cias humanas tratadas com F1,0, esta fra??o n?o promoveu citotoxicidade significativa sobre a membrana de hem?cias. F1,0 exibiu baixa atividade anticoagulante, causando moderada inibi??o direta da atividade enzim?tica da trombina. Esta fra??o promoveu estimula??o de cerca de 4,6 vezes na s?ntese de heparam sulfato (HS) pelas c?lulas endoteliais da aorta de coelho (RAEC), em cultura, quando comparadas com as c?lulas n?o tratadas com F1,0. A fra??o dessa alga mostrou atividade antiproliferativa sobre as c?lulas RAEC, causando aumento no n?mero de c?lulas na fase S, impedindo a progress?o do ciclo celular. Assim, F1,0 apresentou a??o citost?tica e n?o citot?xica sobre esta linhagem celular. Esses resultados sugerem que F1,0 de H. musciformis tem potencial antioxidante, efeito importante para um composto utilizado como alimento e na ind?stria aliment?cia, podendo ser uma alternativa na ind?stria aliment?cia para a preven??o do decaimento da qualidade dos alimentos contendo lip?dio devido a peroxida??o lip?dica, uma vez que a fra??o em estudo exibiu forte a??o inibit?ria sobre a peroxida??o lip?dica. Al?m disso F1,0 apresenta forte a??o antitromb?tica promovendo a estimula??o da s?ntese de HS antitromb?tico pelas c?lulas endoteliais, sendo ?til na preven??o da trombose, devido tamb?m a sua a??o inibit?ria sobre as esp?cies reativas do oxig?nio (ROS) em alguns sistemas in vitro, estando envolvidos na promo??o de estado de hipercoagulabilidade.

Made available in DSpace on 2014-12-17T14:03:44Z (GMT). No. of bitstreams: 1 ThiagoGC_DISSERT.pdf: 2736665 bytes, checksum: 120a3ba44fefe1ccd9373aeb0ff1629f (MD5) Previous issue date: 2014-02-06 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior / Seaweeds are a major source of biologically active compounds . In the extracellular matrix of these organisms are sulfated polysaccharides that functions as structural components preventing it against dehydration. The fraction 0.9 (FucB) rich in sulfated fucans obtained from brown seaweed Dictyota menstrualis was chemical characterized and evaluated for pharmacological activity by testing anticoagulant activity, stimulatory action on the synthesis of an antithrombotic heparan sulfate, antioxidant activity and its effects in cell proliferation. The main components were FucB carbohydrates (49.80 ? 0.10 %) and sulfate (42.30 ? 0.015 %), with phenolic compounds ( 3.86 ? 0.016 %) and low protein contamination ( 0.58 ? 0.001 % ) . FucB showed polydisperse profile and analysis of signals in the infrared at 1262, 1074 and 930 cm -1 and 840 assigned to S = O bonds sulfate esters , CO bond presence of 3,6- anhydrogalactose , β -D- galactose non- sulfated sulfate and the axial position of fucose C4 , respectively. FucB exhibited moderate anticoagulant activity , the polysaccharides prolonged time (aPTT ) 200 ug ( > 90s ) partial thromboplastin FucB no effect on prothrombin time (PT), which corresponds to the extrinsic pathway of coagulation was observed. This stimulation promoted fraction of about 3.6 times the synthesis of heparan sulfate (HS) by endothelial cells of the rabbit aorta ( RAEC ) in culture compared with cells not treated with FucB . This has also been shown to compete for the binding site with heparin. The rich fraction sulfated fucans exhibited strong antioxidant activity assays on total antioxidant (109.7 and 89.5 % compared with BHT and ascorbic acid standards ) , reducing power ( 71 % compared to ascorbic acid ) and ferric chelation ( 71 , comparing with 5 % ascorbic acid). The fraction of algae showed cytostatic activity on the RAEC cells revealed that the increase of the synthesis of heparan sulfate is not related to proliferation. FucB showed antiproliferative action on cell lines modified as Hela and Hep G2 by MTT assay . These results suggest that FucB Dictyota menstrualis have anticoagulant , antithrombotic , antioxidant potential as well as a possible antitumor action, promoting the stimulation of the synthesis of antithrombotic HS by endothelial cells and is useful in the prevention of thrombosis, also due to its inhibitory action on species reactive oxygen ( ROS ) in some in vitro systems , being involved in promoting a hypercoagulable state / Algas marinhas s?o uma das principais fontes de compostos biologicamente ativos. Na matriz extracelular desses organismos existem os polissacar?deos sulfatados que funcionam como componente estrutural prevenindo-a contra desidrata??o. A fra??o 0,9 (FucB) rica em fucanas sulfatadas obtida da alga marrom Dictyota menstrualis foi caracterizada quimicamente e avaliada quanto a atividade farmacol?gica por meio de ensaios de atividade anticoagulante, a??o estimulat?ria sobre a s?ntese de heparam sulfato antitromb?tico, atividade antioxidante e seus efeitos na prolifera??o celular. Os principais componentes da FucB foram carboidratos (49,80 ? 0,10%) e sulfato (42,30 ? 0,015%), apresentando compostos fen?licos (3,86 ? 0,016%) e baixa contamina??o prot?ica (0,58 ? 0,001%). FucB mostrou perfil polidisperso e sinais na an?lise de infravermelho em 1262, 1074 e 930 e 840 cm-1 atribu?dos a liga??es S=O de ?steres de sulfato, presen?a de liga??o C-O de 3,6-anidrogalactose, β-D-galactose n?o sulfatada e sulfato na posi??o axial do C4 da fucose, respectivamente. FucB exibiu moderada atividade anticoagulante, este polissacar?deo prolongou o tempo de tromboplastina parcial activada (aPTT) a 200 ug (>90s) n?o foi observado qualquer efeito de FucB sobre o tempo de protrombina (PT), que corresponde a via extr?nseca da coagula??o. Esta fra??o promoveu estimula??o cerca de 3,6 vezes na s?ntese de heparam sulfato (HS) pelas c?lulas endoteliais da aorta de coelho (RAEC), em cultura, quando comparadas com as c?lulas n?o tratadas com FucB. Esta tamb?m demonstrou competir pelo s?tio de liga??o com a heparina. A fra??o rica em fucanas sulfatadas exibiu forte a??o antioxidante sobre os ensaios de antioxidante total (109,7 e 89,5% comparados com padr?es BHT e ?cido asc?rbico), poder redutor (71% comparado ao ?cido asc?rbico) e quela??o f?rrica (71,5% comparando com ?cido asc?rbico). A fra??o dessa alga mostrou atividade citost?tica sobre as c?lulas RAEC revelando que o aumento da s?ntese de heparan sulfato n?o est? relacionado ? prolifera??o. FucB apresentou a??o antiproliferativa sobre linhagens celulares modificadas como Hela e Hep G2 pelo ensaio de MTT. Esses resultados sugerem que FucB de Dictyota menstrualis tem potencial anticoagulante, antitromb?tico, antioxidante bem como uma poss?vel a??o antitumoral, promovendo a estimula??o da s?ntese de HS antitromb?tico pelas c?lulas endoteliais, sendo ?til na preven??o da trombose, devido tamb?m a sua a??o inibit?ria sobre as esp?cies reativas do oxig?nio (ROS) em alguns sistemas in vitro, estando envolvidos na promo??o de estado de hipercoagulabilidade

Medical devices, such as catheters and heart valves, are an important part of patient care. However, blood-contacting devices can activate the blood coagulation cascade to produce factor (f) Xa, the clotting enzyme that induces thrombin generation. By activating platelets and converting soluble fibrinogen to fibrin, thrombin leads to blood clot formation. Blood clots that form on medical devices create problems because they may foul the device and/or serve as a nidus for infection. In addition, clots can break off from the device, travel through the circulation and lodge in distant organs; a process known as embolization. This is particularly problematic with central venous catheters because clots that form on them can break off and lodge in pulmonary arteries, thereby producing a pulmonary embolism. Similarly, clots that form on heart valves can break off and lodge in cerebral arteries, thereby producing a stroke. Therefore, anticoagulants, blood thinning drugs, are frequently used to prevent clotting on medical devices. Conventional anticoagulants, such as heparin and warfarin, target multiple clotting factors. Heparin binds to antithrombin in plasma and accelerates the rate at which it inhibits fXa, thrombin and many other clotting enzymes. Warfarin, which is a vitamin K antagonist, attenuates thrombin generation by interfering with the synthesis of the vitamin K-dependent clotting factors, which include fX and prothrombin, the precursor of thrombin. In contrast to heparin and warfarin, more recent anticoagulants inhibit only a single clotting enzyme. For example, fondaparinux, a synthetic heparin fragment, only inhibits fXa and dabigatran, an oral thrombin inhibitor, only targets thrombin. Although effective for many indications, fondaparinux was less effective than heparin for preventing clotting on catheters in patients undergoing heart interventions and dabigatran was less effective than warfarin for preventing strokes in patients with mechanical heart valves. The failure of these new anticoagulants highlights the need for a better understanding into the drivers of clotting on medical devices. Therefore, the overall purpose of this thesis is to gain this understanding so that more rational approaches to its prevention can be identified. In the classical model of blood coagulation, clotting is triggered via two distinct pathways; the tissue factor (TF) pathway or extrinsic pathway and the contact pathway or intrinsic pathway; pathways which are initiated by fVIIa and fXIIa, respectively. The mechanism by which medical devices initiate clotting is uncertain. Platelet and complement activation and microparticle formation have been implicated, which would drive clotting via the TF pathway. Alternatively, medical devices can bind and activate fXII, thereby initiating the contact pathway. We hypothesized that medical devices trigger clotting via the contact pathway and induce the local generation of fXa and thrombin in concentrations that exceed the capacity of fondaparinux and dabigatran to inhibit them. To test this hypothesis, we used catheters as a prototypical medical device and we used a combination of in vitro and rabbit models. Several lines of evidence indicate that catheters initiate clotting via the contact pathway. First, catheter segments shortened the clotting time of human plasma, and this activity was attenuated in fXII- or fXI-deficient plasma, which are key components of the contact pathway, but not in fVII-deficient plasma, which is the critical component of the extrinsic pathway. Second, corn trypsin inhibitor (CTI), a potent and specific inhibitor of fXIIa, attenuates catheter thrombosis. Third, selective knockdown of fXII or fXI with antisense oligonucleotides attenuated catheter-induced thrombosis in rabbits, whereas knockdown of fVII had no effect. Therefore, these results revealed the importance of the contact pathway in device-associated thrombosis, and identified CTI or fXII or fXI knockdown as novel strategies for preventing this problem. Focusing on fXIIa as the root cause of medical device associated clotting, we coated catheters with CTI using a polyethylene glycol (PEG) spacer. In addition to unmodified catheters, other controls included catheters coated with albumin via a PEG spacer or catheters coated with PEG alone. Compared with unmodified catheters or with the other controls, CTI-coated catheters attenuated clotting in buffer or plasma systems and were resistant to occlusion in rabbits. These findings support the concept that catheter-induced clotting is driven via the contact pathway and identify CTI coating as a viable strategy for its prevention. We next set out to test the hypothesis that fondaparinux and dabigatran, which inhibit fXa and thrombin, respectively, are less effective than heparin, which inhibits multiple clotting enzymes. Fondaparinux and dabigatran were less effective than heparin at preventing catheter induced clotting and thrombin generation, respectively. Likewise, in a rabbit model of catheter thrombosis, fondaparinux was less effective than heparin and dabigatran was only effective when administered at doses that yielded plasma dabigatran levels similar to those found at peak in human given the drug; at trough levels, dabigatran was no better than placebo. Finally, we also showed synergy between heparin and either fondaparinux or dabigatran. Thus, when co-administered to rabbits in doses that on their own had no effect, the combination of fondaparinux or dabigatran plus heparin extended the time to catheter thrombosis. These findings support the hypothesis that when catheters trigger clotting via the contact pathway, fXa and thrombin are generated in concentrations that overwhelm the capacity of fondaparinux or dabigatran to inhibit them. Furthermore, the synergy between heparin and fondaparinux or dabigatran has clinical implications because it explains why supplemental heparin attenuated the risk of catheter thrombosis in patients treated with fondaparinux who underwent cardiac procedures and it identifies the potential role of supplemental heparin in dabigatran-treated patients who require such interventions. In summary, we have shown that catheters trigger clotting via the contact pathway and have identified CTI coating or fXII or fXI knockdown as viable strategies for prevention of this problem. In addition, for prevention of catheter thrombosis, we also have shown that heparin, which inhibits multiple coagulation enzymes, is more effective than fondaparinux or dabigatran, which only inhibit fXa or thrombin, respectively; findings consistent with the clinical observations. Moreover, the synergy that we observed between fondaparinux or dabigatran and heparin identifies supplemental heparin as strategy for preventing catheter thrombosis in patients receiving these drugs. Taken together, these studies provide insight into the mechanisms of catheter thrombosis and potential strategies for its prevention. / Thesis / Doctor of Philosophy (PhD)