10.4081/btvb.2022.12
Defining the bleeding risk in patients with FVII-deficiency is not easy. Aim of this study is to define correlation and differences between three different scores and the thrombin generation assay (TGA) in correctly evaluating the hemorrhagic phenotype in a group of FVII-deficient patients. Fifty-seven patients patients with FVII-deficiency whose hemorrhagic phenotype was assessed by Mariani, ISTH/SSC- Bleeding Assessment Tool (BAT) and Di Minno scores, and by the TGA, were enrolled in this study. TGA parameters (LagTime, Peak, ttPeak, ETP - endogenous thrombin potential) highlighted how both LagTime and ttPeak can discriminate major bleeders from the others, while the same conclusion could not be reached by the ETP and Peak. However, no TGA parameter was found to be useful in separating the mild hemorrhagic phenotype from the moderate one. Scores and TGA were found to be able to only define the severe hemorrhagic phenotypes. None of the methods was able to exactly discriminate the other phenotypes. Given these results, there is therefore a risk of either underestimating or overestimating the potential bleeding risk in patients with non-severe FVII-deficiency.
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2785-5309
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Ezio  Zanon
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Bleeding, Thrombosis and Vascular Biology
Haemorrhagic phenotypes
Comparison among three different bleeding scores and the thrombin generation assay to assess the different hemorrhagic phenotypes in patients with FVII deficiency
Text.Serial.Journal
https://www.btvb.org/btvb
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Original Articles
2022-05-23
2022-01-16
2022-05-23
2022-07-14
Bleed Thromb Vascul Biol
Ezio  Zanon
2022/05/23
10.4081/btvb.2022.12
General Medicine, Padua University Hospital, Padua
2785-5309
2
Haemorrhagic phenotypes
en
Palla R, Siboni SM, Menegatti M, et al. European Network of Rare Bleeding Disorders (EN-RBD) Group. Establishment of a bleeding score as a diagnostic tool for patients with rare bleeding disorders. Thromb Res 2016;148:128–34.
Comparison among three different bleeding scores and the thrombin generation assay to assess the different hemorrhagic phenotypes in patients with FVII deficiency
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1
                                                                                                             ORIGINAL ARTICLE

Comparison among three different bleeding scores and the thrombin generation
assay to assess the different hemorrhagic phenotypes in patients with FVII
deficiency
Samantha Pasca,1 Cristina Santoro,2 Chiara Ambaglio,3 Marisanta Napolitano,4 Marta Milan,5 Letizia Natali,6
Silvia Nannizzi,6 Filippo Mori,6 Paolo Simioni,7 Ezio Zanon7
1
  Medicine Department (DIMED)/Biomedical Sciences Department, Padua University Hospital, Padua, Italy; 2Umberto I University
Hospital of Rome, Italy; 3Transfusion Medicine, Hospital of Treviglio (BG), Italy; 4Center of Hemorrhagic and Thrombotic Diseases,
University of Palermo, Italy; 5Internal Medicine, Hospital of Rovigo, Italy; 6Research and Innovation Kedrion S.p.A., Lucca, Italy;
7
  General Medicine, Padua University Hospital, Padua, Italy



  Correspondence: Samantha Pasca, Medicine Department                        ABSTRACT
  (DIMED)/Biomedical Sciences Department, Padua University                       Defining the bleeding risk in patients with FVII-deficiency
  Hospital, Via Giustiniani 2, 35128 Padua, Italy.
                                                                             is not easy. Aim of this study is to define correlation and differ-
  E-mail: sampasca27@gmail.com
                                                                             ences between three different scores and the thrombin genera-
                                                                             tion assay (TGA) in correctly evaluating the hemorrhagic




                                                                                               ly
  Key words: FVII deficiency, bleeding scores, thrombin generation
  assay, hemorrhagic phenotypes.                                             phenotype in a group of FVII-deficient patients. Fifty-seven pa-




                                                                                       on
                                                                             tients patients with FVII-deficiency whose hemorrhagic pheno-
  Acknowledgements: The authors would thank the Research & In-               type was assessed by Mariani, ISTH/SSC- Bleeding Assessment
  novation of Kedrion S.p.A for carrying out the TGA analyses and            Tool (BAT) and Di Minno scores, and by the TGA, were en-




                                                                                 e
  statistics.                                                                rolled in this study. TGA parameters (LagTime, Peak, ttPeak,
                                                                             ETP - endogenous thrombin potential) highlighted how both
                                                                            us
  Contributions: MM and EZ designed the study; SP managed the                LagTime and ttPeak can discriminate major bleeders from the
  study and wrote the paper; LN, SN, and FM carried out the TGA              others, while the same conclusion could not be reached by the
  investigations. All authors take responsibility for the integrity of
                                                                            al
                                                                             ETP and Peak. However, no TGA parameter was found to be
  the work as a whole and have given final approval of the version
  to be published.                                                           useful in separating the mild hemorrhagic phenotype from the
                                                         ci

                                                                             moderate one. Scores and TGA were found to be able to only
                                                                             define the severe hemorrhagic phenotypes. None of the methods
                                                       er


  Conflict of interest: The authors declare no potential conflict of in-
  terest.                                                                    was able to exactly discriminate the other phenotypes. Given
                                                                             these results, there is therefore a risk of either underestimating
                                                      m




  Funding: This study has been supported by the “Bayer Award                 or overestimating the potential bleeding risk in patients with
  Program”.                                                                  non-severe FVII-deficiency.
                                          om




  Ethical Approval: All procedures performed in this study involving
  human participants were in accordance with the ethical standards
                                    -c




  of the institutional and/or national research and with the 1964            INTRODUCTION
  Helsinki declaration and its later amendments or comparable eth-
                           on




  ical standards.                                                                 The FVII deficiency is the most frequent among rare
                                                                             congenital bleeding disorders, estimated at 1 in 500.000,
  Informed consent: The patients signed the informed consent as re-
                                                                             apparently without any sex, racial or ethnic predilection.1,2
                     N




  quested by Ethical Committees.
                                                                             The prevalence of FVII deficiency among the general pop-
  Received for publication: 16 January 2022.                                 ulation is probably high due to large number of asympto-
  Accepted for publication: 13 May 2022.                                     matic or poorly symptomatic subjects. This is an inherited,
                                                                             autosomal recessive defect. The factor VII protein is part
  Publisher’s note: All claims expressed in this article are solely those
  of the authors and do not necessarily represent those of their affili-     of the initiating complex of the extrinsic coagulation path-
  ated organizations, or those of the publisher, the editors and the re-     way, laboratory diagnosis is easy, in fact FVII deficiency
  viewers. Any product that may be evaluated in this article or claim        is the only congenital bleeding disorder diagnosed by pro-
  that may be made by its manufacturer is not guaranteed or endorsed         longed prothrombin time (PT), while activated partial
  by the publisher.
                                                                             thromboplastin time (aPTT) is within normal range. FVII
  ©
   Copyright: the Author(s), 2022                                            deficiency may be mild, moderate, or severe,3,4 based on
  Licensee PAGEPress, Italy                                                  the plasmatic level of the coagulation factor, but bleeding
  Bleeding, Thrombosis and Vascular Biology 2022; 1:12                       phenotype could be different among subjects with similar
  doi:10.4081/btvb.2022.12
                                                                             levels of plasma FVII. The subjects presenting low levels
  This work is licensed under a Creative Commons Attribution-                of FVII may have symptoms like hemophilia patients.
  NonCommercial 4.0 International License (CC BY-NC 4.0).                    Women with FVII deficiency can have severe menorrhagia,
                                                                             bleeding during delivery or post-partum.5,6

                                              Bleeding, Thrombosis and Vascular Biology 2022; 1:12
16                                                        S. Pasca et al.




    The published reports highlighted as in some cases the               The study protocol was approved by each institution’s
severity of FVII deficiency cannot correlate with the                Ethical Committee and was conducted in accordance with
bleeding symptoms.7 This observation is often based on               the principles of the Declaration of Helsinki and with
the hemophilia categorization. This classification has been          local laws and regulations. All patients provided written
considered not correct by the ISTH-SSC and replaced in               informed consent. In the case of minor patients, the in-
2012,8 based on the results of the European Network of               formed consent was signed by parents.
Rare Bleeding Disorders (EN-RBD) registry.9 In the
Seven Treatment Evaluation Registry (STER) most major                Methods
bleeds occurred in patients with plasmatic FVII <3%,
                                                                         All clinical and anamnestic information of the patients
while minor bleeds were more frequent in subjects with a
                                                                     have been collected through the compilation of a paper
moderate/mild disease. Patients presenting major bleeding
                                                                     case report form (CRF) at enrolment.
at enrolment resulted also at high risk for severe hemor-
                                                                         The severity of FVII deficiency was classified follow-
rhagic recurrences.10 Intracranial bleeding was usually
                                                                     ing the “Consensus Definitions in Rare Bleeding Disor-
considered restricted to a few areas in which consan-
guineous marriages are frequent and most patients are ho-            ders of the Factor VIII/Factor IX Scientific and
mozygous for the FVII defect, but the data reported in the           Standardization Committee (SSC) of the International So-
IF7 Registry also showed a high incidence of major bleed-            ciety on Thrombosis and Hemostasis (ISTH)” and based




                                                                                             ly
ing in patients with severe FVII at early onset.11 Sponta-           on the results of the European Network of Rare Bleeding
                                                                     Disorders (EN-RBD) Registry.8,9 Severe disease: FVII




                                                                                      on
neous major bleeds in patients presenting FVII level
>20% were practically null, but also in this population dif-         level <10% (high risk for spontaneous major bleeding);
ferentiation between bleeders and not bleeders could be              moderate disease: FVII level 10-20% (risk for mild spon-
                                                                     taneous or traumatic bleeding); mild disease FVII level


                                                                                 e
useful to avoid during surgery useless or harmful replace-
ment therapy.                                                        >20 (usually asymptomatic patients).
                                                                            us
    With this background the management of patients pre-
senting FVII deficiency can be very difficult, a correct as-         Bleeding scores
                                                                    al
sessment is needed to predict the bleeding risk of each                   Bleeding risk was assessed for each patient by three
patient. Different scores have been created to define the
                                                      ci

                                                                     different scores:
hemorrhagic phenotype: Mariani score;10 ISTH/SSC-BAT                 i. Mariani score: the patients have been classified as a)
                                                    er



bleeding assessment tool;13,14 or Di Minno classification.10              severe bleeders if reported at least one intracranial
All these tools are equally easy to use, but not all have the             hemorrhage (ICH) and/or gastrointestinal (GI) bleed-
                                                   m




same accuracy. Bleeding classifications may therefore not                 ing and/or hemarthrosis in association with other
                                          om




be exactly superimposable.                                                bleeding events; b) moderate bleeders if reported three
    In addition to bleeding scores, the use of Thrombin                   or more bleeding events excluding ICH, GI bleeding
Generation Assay (TGA) to define the hemorrhagic phe-                     and hemarthrosis; c) mild bleeders if reported one or
                                    -c




notype of FVII deficiency patients can be a valuable op-                  two bleeding symptoms excluding ICH, GI bleeding
tion for clinicians. TGA evaluates thrombin generation                    and hemarthrosis; d) non-bleeders.12
                             on




and its disappearance, thus assessing the balance between            ii. ISTH/SSC-BAT score: the patients have been classi-
these two different moments.15,16                                         fied with (abnormal/positive) or without (normal/neg-
                         N




                                                                          ative) bleeding risk based on the bleeding score (BS)
Objective                                                                 obtained by the questionnaire, and different for age
   The purpose of this study is to define whether exists a                and sex. Normal/negative BS: children <3; males <4;
correlation between three different bleeding scores and                   and female <6.13,14
TGA in the prediction of the hemorrhagic phenotype in                iii. Di Minno classification: the patients have been clas-
subjects with FVII deficiency.                                            sified as a) asymptomatic, b) minor bleeders or c)
                                                                          major bleeders based on the characteristic of the first
                                                                          bleeding event (no bleeding; minor bleeding: epis-
MATERIALS AND METHODS                                                     taxis, ecchymosis, gum bleeds, hematuria, menorrha-
                                                                          gia, umbilical cord bleeding, hemorrhoidal bleeding
Patients
                                                                          muscle or subcutaneous hematoma; major bleeding:
    This is a spontaneous, prospective, multicenter study                 ICH, GI bleeding and hemarthrosis).10
that included all patients of any age with FVII deficiency                Each score then divided the patients into different
referred to four Italian Hemophilia Centers. Data collec-            groups based on their bleeding risk. These groups were
tion started in January 2019 and ended in December                   subsequently compared with the results obtained by the
2020.                                                                thrombin generation assay.

                                     Bleeding, Thrombosis and Vascular Biology 2022; 1:12
                      Methods to assess different hemorrhagic phenotypes in patients with FVII deficiency                    17



Thrombin generation assay
                                                                   RESULTS
     The TGA analysis was performed following the
Hemker protocol.17                                                 Descriptive analyses
     Thrombin generation curves were calculated in com-                Overall, fifty-seven total patients were enrolled in four
parison to a calibration curve measured in the same sam-           different Italian Hemophilia Centers (Padua, Palermo,
ple with a dedicated software (Thrombinoscope™,                    Pavia and Rome), 63.2% of them were females, only one
Thrombinoscope BV, Maastricht, The Netherlands).                   patient was black, the others were all Caucasian. Mean
     All reagents for TGA were supplied by Diagnostica             age at diagnosis was 26 years (range 9 months – 66 years).
Stago (Asnières-sur-Seine, France).                                Family history for FVII deficiency was found in the
     A negative and a positive control, Cryocheck Normal           45.6% of cases. 31.6% of subjects had a severe disease,
Reference Plasma – Ref. Plasma (HIT), and Factor VII               14.0% moderate, and the remaining 54.4% mild. Mean
Deficient Plasma – FVII DP (Affinity biological), respec-          FVII plasma level was 23.0% (range <1-50%). Eight pa-
tively, were included in the assay to assess the correct           tients (14.0%) presented a cardiovascular disease at diag-
thrombogram for each patient. A first set-up of the TGA            nosis, arterial hypertension was present in 7/8 of them,
method was then carried out on these controls to deter-            while the remaining presented an ischemic cardiopathy
mine the most suitable Tissue Factor (TF) concentration            (IC). The same patient with IC also presented a previous




                                                                                    ly
to trigger the coagulation reaction. Each sample                   thrombosis in the upper left limb.
(patient/control) was analyzed in duplicate (each duplicate




                                                                             on
                                                                       Mean age of twenty healthy controls was 31 years
represented by n=3 technical replies, applying an accept-          (range 19-57 years), and mean plasma FVII level was
ability criterion ≤15%, as a coefficient of variation (CV)         83% (range 72-126%).
between the replicates.


                                                                       e
     Using the Thrombin Generation Assay (TGA) method            usBleeding scores
we have analyzed:
i. LagTime: time needed to detect the thrombin forma-                   The three scores were applied to all 57 patients. For
                                                          al
     tion onset                                                    each score the following groups were identified in which
ii. ETP: endogenous thrombin potential; it detects the             the patients were thus distributed:
                                             ci


     amount of thrombin formed in a defined period, which          i. Mariani score: 13/57 (22.8%) severe, 11/57 (19.3%)
                                           er



     corresponds to the area under the curve (AUC)                      moderate, 33/57 (57.9%) mild
iii. Peak Thrombin: concentration of the thrombin peak;            ii. Di Minno classification: 13/57 (22.8%) major, 40/57
                                          m




     corresponding to the maximum amount of thrombin                    (70.2%), 4/57 asymptomatic (7.0%)
     reached during the thrombogram formation                      iii. ISTH/SSC-BAT: 27/30 (47.4%) abnormal, 30/57
                                 om




iv. ttPeak: time to Peak; corresponding to time needed to               (52.6%) normal
     reach the maximum amount of thrombin                               In 34/57 patients (59.6%) the bleeding risk obtained
                                                                   by each different score was in agreement with the severity
                            -c




     All the obtained data have been compared with those
obtained from twenty healthy subjects equally divided be-          of disease based on FVII plasma level. Conversely, in
                     on




tween males and females and collected at the participating         12/57 patients (21.1%) with severe or moderate disease
Centers.                                                           one or more bleeding scores showed a hemorrhagic risk
                N




     We have subsequently evaluated the derived parame-            lower than expected; while in the remaining 11/57 patients
ter Velocity Index, defined by the peak thrombin concen-           (19.3%), almost all mild, one or more of the bleeding
tration divided by the difference between time to peak and         scores were higher than supposed.
lag time.                                                               Considering only the ISTH/SSC-BAT bleeding score
                                                                   (BS) a statistically significant difference (p<0.05) was ob-
Statistics                                                         tained comparing severe patients (median score 11.0) with
                                                                   mild (median score 3.0) or moderate (median score 3.5)
    Descriptive statistical analyses were performed using
                                                                   patients respectively. No difference in BS between mild
SAS statistical software version 9.2 (SAS, Cary, NC) in
                                                                   and moderate was highlighted.
Windows 7 professional environment.
    The TGA statistical results analyses were performed
                                                                   TGA assay
using Minitab 17 software. The ANOVA test (α=0.05)
with the Tukey Pairwise comparison was performed to an-               Complete assessment was performed in 53 subjects;
alyze all the parameters with normal data distribution,            four patients (PV009, PV010, PV014 and PD005) were
while the non-parametric Kruskal-Wallis test was used for          excluded from TGA analyses. PV009 and PV014 were
to analyze the remaining parameters with non-normal dis-           excluded due to a Coefficient of Variation (CV) <15%,
tribution.                                                         lower than the acceptability criterion of method; while

                                    Bleeding, Thrombosis and Vascular Biology 2022; 1:12
18                                                          S. Pasca et al.




PV010 and PD005 were excluded due to the generation                      the Mariani score. On the other hand, no parameter was
of a low amount of thrombin, not sufficient for analysis.                effective in discriminating subjects with a moderate phe-
                                                                         notype who are therefore not distinguishable from either
TGA vs FVII plasma level                                                 mild or severe patients.
                                                                             The box plot comparing the TGA data with the hem-
    The LagTime and the ttPeak since they have a normal
                                                                         orrhagic phenotypes obtained with the Mariani score is
distribution were analyzed with ANOVA test with Tukey
                                                                         shown in Figure 2.
Pairwise Comparisons. In this case both, LagTime and tt-
Peak showed a difference statistically significant (p<0.05)
                                                                         TGA vs Di Minno classification
comparing to healthy control, while only for LagTime this
difference was found comparing different phenotypes.                         LagTime and ttPeak were found to be able to discrim-
Graphically, in almost all the patients analyzed, those with             inate between major bleeders versus minor bleeders and
the most severe hemorrhagic phenotype have a higher                      major bleeders versus asymptomatic ones. On the other
curve, a situation not highlighted with ETP and Peak.                    hand, no parameter could differentiate the minor bleeders
These last two parameters, not presenting a normal distri-               from the asymptomatic ones.
bution, were analyzed with the non-parametric Kruskal-                       The box plot comparing the TGA data with the hem-
Wallis test. A significant difference was found for both                 orrhagic phenotypes obtained with the Di Minno classifi-
                                                                         cation is shown in Figure 3.




                                                                                                      ly
parameters by comparing the different groups with in-
creasing hemorrhagic phenotype, p=0.002 for Peak and




                                                                                            on
p=0.001 for ETP.                                                         TGA vs ISTH/SSC-BAT score
    Compared to healthy control the ttPeak was increased                    Comparative statistical analyzes showed that Lag-
of 2.3-fold in severe patients, 1.4 in cases of moderate, and


                                                                                      e
                                                                         Time, ttPeak and Peak were able to discriminate between
1.3 in case of mild ones; while the LagTime was increased                     us
                                                                         normal and abnormal subjects according to the
3.2-fold in severe subjects, 1.5 in both, moderate and mild              ISTH/SSC-BAT score. Only the ETP does not appear to
ones. The Peak was reduced by 38.9% in patients with se-                 be useful in differentiating the two groups.
                                                                         al
vere phenotype, by 14.8% for moderate, and by 13.2% for
mild; while ETP was reduced by 27% compared to healthy
                                                        ci


control, while by 16.8% and by 17.9% for moderate and
                                                      er



mild subjects, respectively. Representative TGA curves of
severe, moderate, and mild bleeding phenotypes, compared
                                                     m




to healthy controls were shown in Figure 1.
    All the TGA results were subsequently compared with
                                           om




the three different scores (Mariani score – Di Minno clas-
sification – ISTH/SSC-BAT score).
                                       -c




TGA vs Mariani score
                                 on




    The comparison carried out between the four different
parameters of the TGA, and the different groups of pa-
                            N




tients based on the Mariani score allowed us to establish
that only the LagTime and the ttPeak are able to discrim-
                                                                         Figure 1. TGA curves of severe, moderate and mild bleeding
inate subjects with mild hemorrhagic phenotype from
                                                                         phenotypes, compared to healthy controls (CRLT).
those with severe hemorrhagic phenotype, according to


Table 1. Statistical comparison among TGA (all the 4 parameters) and the 3 different bleeding scores.
                Plasmatic FVII (%)              Mariani score                 Di Minno classification     ISTH/SCC-BAT score
Lag-Time        Semi-discriminative          Semi-discriminative                Semi-discriminative        Semi-discriminative
                 (severe vs others)*     (severe vs mild/no-bleeders)*           (major vs minor)*        (abnormal vs normal)*
ETP             Non-discriminative            Non-discriminative                Non-discriminative          Non-discriminative
Peak            Non-discriminative            Non-discriminative                Non-discriminative         Semi-discriminative
                                                                                                          (abnormal vs normal)*
ttPeak          Semi-discriminative          Semi-discriminative                Semi-discriminative        Semi-discriminative
                 (severe vs others)*     (severe vs mild/no-bleeders)*           (major vs minor)*        (abnormal vs normal)*
*Discriminative results.


                                       Bleeding, Thrombosis and Vascular Biology 2022; 1:12
                      Methods to assess different hemorrhagic phenotypes in patients with FVII deficiency                    19



    The box plot comparing the TGA data with the hem-              hemorrhagic scores and laboratory assays that can help
orrhagic phenotypes obtained with the ISTH/SSC-BAT                 them in clinical practice.
score is shown in Figure 4.                                            In a recent article published by Toret et al.,18 27 chil-
    A summary of the results has been proposed in Table 1.         dren with plasmatic FVII <35% were included in a study
    The derived parameter Velocity Index (VI) was sub-             designed to compare the global assays, thromboelastog-
sequently obtained for each patient. Mean VI of mild sub-          raphy (TEG) and TGA, with the ISTH/SSC-BAT score in
jects was 63.65 (±56.59) nM/min, higher than moderate              assessing their bleeding phenotype. The FVII level re-
or severe ones in which this parameter was 37.70 (±26.17)          sulted negatively correlated with the LagTime, of TGA,
nM/min and 31.79 (±18.27) nM/min, respectively. Com-               and positively with the ttPeak, while no significant corre-
pared with FVII plasma level, this index resulted be useful        lation was showed between the FVII level and any TEG
in discriminating severe patients from mild, but not from          parameter, similar as observed in our patients in which
moderate ones. In no case, the VI was able to discriminate         the same TGA parameters seem to be able to discriminate
the different patients presenting different hemorrhagic            between the major bleeders and the others. The medians
phenotype as classified by the three different scores              of BS reported by Toret et al. were 8.3 and 2.9 in the se-
                                                                   vere and mild/moderate group, respectively, and the dif-
                                                                   ference was statistically significant. Also, in our case the
DISCUSSION                                                         difference between the median BS in severe patients




                                                                                    ly
    The plasmatic FVII level cannot correlate with the             (11.0) and the median BS in mild (3.0) or moderate (3.5)




                                                                             on
bleeding phenotype.7 With this background it is very dif-          subjects, was statistically significant (<0.05); and only in
ficult to manage the people with FVII deficiency cor-              about half of them, FVII level correlate with the results
rectly, for this reason, clinicians try to find reliable           of all three hemorrhagic scores. The ISTH/SSC-BAT



                                                                       e
                                                                 us
                                                          al
                                             ci
                                           er
                                          m
                                 om
                            -c
                     on
                N




Figure 2. Box plot comparing TGA parameters and hemorrhagic phenotypes obtained by Mariani score.


                                    Bleeding, Thrombosis and Vascular Biology 2022; 1:12
20                                                        S. Pasca et al.




score was in fact created to assess the bleeding phenotype           ttPeak were increased threefold compared with those of the
in von Willebrand patients,18 it is not always useful to de-         controls. Like what was observed in our study, in which the
fine the real hemorrhagic phenotype of patients with rare            ETP of severe patients was reduced by 27% compared to
bleeding disorders, such as FVII deficiency. In 2016 Palla           controls, the ttPeak was increased twofold, while the Lag-
et al.20 developed a new Bleeding Score to specifically de-          Time was also increased threefold. Although differences
termine the hemorrhagic phenotype in subjects affected               were observed between moderate/mild subjects and healthy
by RBDs and to distinguish them from healthy people,                 controls, it was not possible to discriminate accurately be-
based on clinical history. The importance of BS in clinical          tween mild or moderate patients. The derived parameter
practice is therefore proven, but no tool has been found             Velocity Index was able only to discriminate severe patients
to be superior to others in accurately classifying the bleed-        from mild, when compared with FVII plasma level.
ing risk of each individual patient. In our study we there-
fore used, in addition to the ISTH/SSC-BAT, also the
Mariani score, and the Di Minno classification and we                CONCLUSIONS
correlated them to the data obtained through the Thrombin                Our study showed that the bleeding tendency of severe
Generation Assay. As in case of the plasmatic FVII level,            patients affected by inherited Factor VII deficiency can
the LagTime and the ttPeak resulted able to discriminate             be equally discriminated from that of others using both,
the severe patients from the others.                                 bleeding scores or TGA, while no discrimination was pos-




                                                                                             ly
    Tran et al.16 analyzed the global assays to define               sible in patients with moderate or mild disease. The cor-




                                                                                      on
whether TEG and TGA could predict the hemorrhagic phe-               rect determination of the hemorrhagic phenotype of
notype in patients with severe FVII deficiency. In case of           patients with FVII deficiency therefore remains an un-
TGA parameters, ETP was reduced to 30% of the healthy                known factor, a difficult to interpret variable, which often



                                                                                 e
controls in platelet poor plasma, while the LagTime and the          makes it difficult to manage by clinicians.
                                                                            us
                                                                    al
                                                      ci
                                                    er
                                                   m
                                          om
                                     -c
                             on
                         N




Figure 3. Box plot comparing TGA parameters and hemorrhagic phenotypes obtained by Di Minno classification.


                                     Bleeding, Thrombosis and Vascular Biology 2022; 1:12
                        Methods to assess different hemorrhagic phenotypes in patients with FVII deficiency                        21




                                                                                       ly
                                                                               on
                                                                         e
                                                                   us
                                                              al
                                                ci
                                              er


Figure 4. Box plot comparing TGA parameters and hemorrhagic phenotypes obtained by ISTH/SCC-BAT score.
                                             m
                                    om




Limitation                                                            6. Napolitano M, Di Minno MN, Batorova A, et al. Women
                                                                         with congenital factor VII deficiency: clinical phenotype and
    First limitation of this study is due to a low number of             treatment options from two international studies. Hemo-
patients, and to a non-homogeneous distribution among
                              -c




                                                                         philia 2016;22:752-9.
the various severity degrees of deficiency. Second limita-            7. Iwaniec T, Zdziarska J, Musiał J, Sanak M. A Retrospective
                       on




tion is due to lack of genetic mutation for each patient still           Analysis of Clinical and Laboratory Data of Patients with
under laboratory assessment.                                             Factor VII Deficiency: A Single Centre Experience.
                                                                         Hamostaseologie 2019;39:368-76.
                  N




                                                                      8. Peyvandi F, di Michele D, Bolton-Maggs PHB, et al. Project
                                                                         on Consensus Definitions in Rare Bleeeding Disorders of
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