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BACKGROUND: Left ventricular thrombus (LVT) can develop in a diverse group of patients with various underlying causes resulting in divergent natural histories and trajectories with treatment. Our aim was to utilise cluster analysis to identify unique clinical profiles among LVT patients and then compare their clinical characteristics, treatment strategies, and outcomes. METHODS: We conducted a retrospective study involving 472 LVT patients whose data was extracted from a tertiary center's echocardiography database, from March 2011 to January 2021. We employed the TwoStep cluster analysis method, examining 19 variables. RESULTS: Our analysis of the 472 LVT patients revealed two distinct patient clusters. Cluster 1, comprising 247 individuals (52.3%), was characterized by younger patients with a lower incidence of traditional cardiovascular risk factors and relatively fewer comorbidities, compared to Cluster 2. Most patients had LVT attributed to an underlying ischaemic condition, with a larger proportion in Cluster 1 being due to post-acute myocardial infarction (68.8%), and Cluster 2 due to ischaemic cardiomyopathy (57.8%). Notably, patients in Cluster 2 exhibited a reduced likelihood of LVT resolution (HR 0.58, 95% CI 0.44 - 0.77, p < 0.001) and a higher risk of all-cause mortality (HR 2.27, 95% CI 1.43 - 3.60, p = 0.001). These associations persisted even after adjusting for variables like anticoagulation treatment, the presence of left ventricular aneurysms, and specific LVT characteristics such as mobility, protrusion, and size. CONCLUSIONS: Through TwoStep cluster analysis, we identified two distinct clinical phenotypes among LVT patients, each distinguished by unique baseline clinical attributes and varying prognoses.

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The coronavirus disease 2019 (COVID-19) pandemic has unveiled numerous clinical challenges, particularly its association with thrombotic events, which significantly contribute to morbidity and mortality. While thrombotic complications such as arterial and venous thromboembolism (VTE) are well-documented, instances of intracardiac thrombus are notably rare. This case report discusses a 60-year-old male with COVID-19 who came to the hospital due to respiratory distress. Despite treatment with remdesivir, the patient's condition worsened prompting further workup. His nuclear medicine (NM) ventilation-perfusion scan was inconclusive, but a 2D echocardiogram showed an intracardiac thrombus in the right atrium (RA) and right ventricle (RV). As the patient's condition worsened, necessitating a transition from nasal cannula to high-flow nasal cannula, a decision was made to treat him with intravenous (IV) thrombolytic therapy. The patient received 100 mg IV alteplase and IV heparin, resulting in significant respiratory improvement and symptomatic relief. A repeat echocardiogram after 48 hours showed normal ejection fraction and complete thrombus resolution. In conclusion, this case highlights the complex link between COVID-19 infection and prothrombotic states, leading to severe complications such as intracardiac thrombus in transit. The successful treatment of this patient through a multidisciplinary approach and thrombolytic therapy underscores the importance of prompt recognition and intervention in high-risk cases.

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Pulmonary embolism (PE) in the context of a right ventricular (RV) thrombus in transit is a special situation requiring a quick response that differs according to many factors. It is a rare but alarming finding. There is no clear guide to date that outlines a common pathway for treatment, as many factors play a role in determining the treatment plan. The mere presence of a thrombus in transit in the right atrium or right ventricle with a concomitant PE carries a higher risk of morbidity and mortality than PE alone. We will examine two cases presenting with PE with concomitant RV multiple thrombi and a background of cancer and diffuse bilateral deep vein thrombosis. One case was treated with anticoagulation alone, and the other with an inferior vena cava (IVC) filter in addition to anticoagulation. They both had a stable course despite their high risks and the frightening appearance of the multiple floating and attached thrombi seen in their echocardiography, some of which newly appeared after the second day of anticoagulation. The cases reflect the effectiveness of echocardiography for detecting and guiding treatment even after starting anticoagulation as well as the good outcome in such cases with anticoagulation alone when no massive PE occurs.

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COVID-19 is an infectious disease caused by the SARS-CoV-2 virus. This epidemic has caused serious socio-economic problems worldwide, with a very high mortality rate. Several articles have been published in the literature showing the consequences of this disease on the human body. Among the most serious complications are venous and arterial thrombosis, which are rarely observed together in the same patient. In this article, we report an exceptional case of a patient with COVID-19 with the combination of intracardiac thrombus (left atrium) and venous thrombosis (splenic vein and portal trunk).

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A myocardial diverticulum is a rare congenital anomaly characterized by pouch-like protrusions within the myocardial wall, which can potentially lead to various cardiac complications. This case report describes a unique presentation of a left ventricular diverticulum (LVD) with an associated apical thrombus, highlighting the diagnostic and management challenges posed by this condition. A 58-year-old man presented to the emergency department with left arm weakness, wrist drop, and chest pain, initially raising concerns for a stroke. Diagnostic evaluations, including echocardiography and magnetic resonance imaging (MRI), revealed a small focal outpouching at the left ventricular apex, consistent with a congenital LVD containing a thrombus. This diagnosis was supported by the patient's historical imaging dating back to 2007, which had similarly identified this outpouching. The patient was managed with anticoagulation therapy, transitioning from heparin to warfarin, alongside standard cardiac care. This case underscores the importance of considering myocardial diverticulum in the differential diagnosis of patients presenting with cardiac symptoms that might initially suggest more common conditions, such as stroke. It also highlights the essential role of echocardiography and MRI in diagnosing and managing myocardial diverticula.

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BACKGROUND: Li-Fraumeni syndrome (LFS) is a rare autosomal dominant cancer-predisposing syndrome, which can manifest as a polymorphic spectrum of malignancies. LFS is associated with an early onset in life, with the majority of cases occurring prior to the age of 46. Notwithstanding the infrequency of primary cardiac tumors, it behooves clinicians to remain vigilant in considering the differential diagnosis of such tumors in LFS patients who present with a cardiac mass. This is due to the markedly elevated risk for malignancy in this particular population, far surpassing that of the general populace. CASE SUMMARY: Herein, we present a case of a 30-year-old female with LFS who was found to have a tricuspid valve leaflet mass. CONCLUSION: This case exemplifies valuable learning points in the diagnostic approach for this exceptionally rare patient population.

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Acute renal infarction, presenting with nonspecific symptoms, such as abdominal pain, nausea, vomiting, and hematuria, can lead to delayed diagnosis due to similarities with other medical conditions. Computed tomography with IV contrast is used to diagnose renal parenchymal infarction, treated through surgical, percutaneous interventions, and anticoagulation therapy. Investigation for the infarction source is crucial, particularly in the absence of prior cardiac issues, necessitating heart rhythm monitoring and an echocardiogram to evaluate paroxysmal atrial fibrillation (PAF) and intracardiac thrombus, respectively. Renal infarction may elevate blood pressure due to renin release, recommending medications like angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. We present a case of renal infarction due to PAF with a concomitant intracardiac thrombus.

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BACKGROUND: Intracardiac thrombus and vascular air embolism represent rare complications in the context of orthotopic liver transplantation. While isolated reports exist for intracardiac thrombus and vascular air embolism during orthotopic liver transplantation, this report presents the first documentation of their simultaneous occurrence in this surgical setting. CASE PRESENTATION: This case report outlines the clinical course of a 60-year-old white female patient with end-stage liver disease complicated by portal hypertension, ascites, and hepatocellular carcinoma. The patient underwent orthotopic liver transplantation and encountered concurrent intraoperative complications involving intracardiac thrombus and vascular air embolism. Transesophageal echocardiography revealed the presence of air in the left ventricle and a thrombus in the right atrium and ventricle. Successful management ensued, incorporating hemodynamic support, anticoagulation, and thrombolytic therapy, culminating in the patient's discharge after a week. CONCLUSIONS: This report highlights the potential for simultaneous intraoperative complications during orthotopic liver transplantation, manifesting at any phase of the surgery. It underscores the critical importance of vigilant monitoring throughout orthotopic liver transplantation to promptly identify and effectively address these rare yet potentially catastrophic complications.

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Background: Cardiac complications occur in 1-6% of cases of Behçet disease (BD) with intracardiac thrombus being the most frequent complication. Endomyocardial fibrosis, less common and occasionally associated with intracardiac thrombus, is reported in <20 case reports of BD, among which, three cases are described to mimic Ebstein disease based on echocardiography. We present the first case in the literature of a 34-year-old man with BD diagnosed with multiple cardiovascular complications, highlighting the challenging diagnosis and treatment of this pathology, especially regarding anticoagulation therapy. Case summary: A 34-year-old man, diagnosed with BD, presented to the Emergency Room with haemoptysis. Computed tomography study of the thorax diagnosed pulmonary arterial aneurysm with multiple arterial thrombi, associated with multiple intracardiac thrombi in the right ventricle and atrium. The echocardiography confirmed the presence of voluminous thrombi in the right ventricle and atrium and showed hypertrabeculation of the right ventricle and a high insertion of the posterior leaflet of the tricuspid valve inducing a moderate tricuspid insufficiency compatible with an Ebstein disease. The cardiac MRI later revealed right ventricular fibrosis consistent with endomyocardial fibrosis and sequelae of myocarditis, also described as BD rare cardiac manifestations. The patient had a favourable outcome under anticoagulant treatment and immunosuppressive drugs. Discussion: The association of multiple cardiovascular complications can occur in a single patient with BD. The endomyocardial fibrosis in the right heart chambers acting as a substrate for thrombus formation and subsequent pulmonary embolism; fibrosis extending to the tricuspid valve inducing an Ebstein-like morphology.

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BACKGROUND: Incorporating cardiac CT with hyperacute stroke imaging may increase the yield for cardioembolic sources. It is not clarified whether stroke severity influences on rates of intracardiac thrombus. We aimed to investigate a National Institutes of Health Stroke Scale (NIHSS) threshold below which acute cardiac CT was unnecessary. METHODS: Consecutive patients with suspected stroke who underwent multimodal brain imaging and concurrent non-gated cardiac CT with delayed timing were prospectively recruited from 1st December 2020 to 30th November 2021. We performed receiver operating characteristics analysis of the NIHSS and intracardiac thrombus on hyperacute cardiac CT. RESULTS: A total of 314 patients were assessed (median age 69 years, 61% male). Final diagnoses were ischemic stroke (n=205; 132 etiology-confirmed stroke, independent of cardiac CT and 73 cryptogenic), transient ischemic attack (TIA) (n=21) and stroke-mimic syndromes (n=88). The total yield of cardiac CT was 8 intracardiac thrombus and 1 dissection. Cardiac CT identified an intracardiac thrombus in 6 (4.5%) with etiology-confirmed stroke, 2 (2.7%) with cryptogenic stroke, and none in patients with TIA or stroke-mimic. All of those with intracardiac thrombus had NIHSS ≥4 and this was the threshold below which hyperacute cardiac CT was not justified (sensitivity 100%, specificity 38%, positive predictive value 4.0%, negative predictive value 100%). CONCLUSIONS: A cutoff NIHSS ≥4 may be useful to stratify patients for cardiac CT in the hyperacute stroke setting to optimize its diagnostic yield and reduce additional radiation exposure.

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Tunneled catheters are frequently used in patients with end-stage renal disease who require hemodialysis access. Catheter-related atrial thrombus is a documented complication of prolonged catheter use. The incidence of catheter-related atrial thrombus is 2% to 29%, with a high mortality rate approaching 20%, raising concerns for serious complications and death in the absence of an established universal management plan. This case series demonstrates the successful use of a minimally invasive approach to treat patients with intracardiac thrombus and high perioperative risk factors using mechanical and aspiration thrombectomy with the FlowTriever system (Inari Medical).

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BACKGROUND: Congenitally corrected levo-transposition of the great arteries (L-TGA) is a congenital heart disease in which the ventricles and great arteries are transposed from their typical anatomy. In L-TGA, the double discordance, atrioventricular and ventriculoarterial, create an acyanotic milieu which allows patients to survive their early decades, however, progressive systemic right ventricle (sRV) dysfunction creates complications later in life. sRV dysfunction and remodeling predisposes patients to intracardiac thrombus (ICT) formation. CASE SUMMARY: A 40-year-old male with L-TGA presented with symptoms of acute decompensated heart failure. In childhood, he had surgical repair of a ventricular septal defect. In adulthood, he developed sRV dysfunction, systemic tricuspid valve (sTV) regurgitation, and left-bundle branch block for which he underwent cardiac resynchronization therapy. Transthoracic echocardiogram showed a sRV ejection fraction of 40%, severe sTV regurgitation, and a newly identified sRV ICT. ICT was confirmed by ultrasound-enhancing agents and transesophageal echocardiography. Our patient was optimized with guideline-directed medical therapy and diuresis. Anticoagulation was achieved with a vitamin K antagonist (VKA) and he was later referred for evaluation by advanced heart failure and heart transplant services. CONCLUSION: Anticoagulation with VKA is the mainstay of treatment in the absence of conclusive data supporting direct oral anticoagulant use in ICT in patients with congenital heart disease. This case illustrates the natural history of L-TGA and highlights the importance of surveillance and monitoring with dedicated cardiac imaging to identify complications.

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A 45-year-old man from El Salvador with no past medical history presented with cough and chest pain. Investigations revealed 60% peripheral eosinophilia (absolute count 12.3 K/uL). Cardiac imaging was consistent with myocarditis with intracardiac thrombus formation. Endomyocardial biopsy confirmed eosinophilic infiltration of the myocardium, and bone marrow biopsy showed hypercellular marrow with 28% eosinophils. Cytogenetics/fluorescence in situ hybridization (FISH) confirmed positive FIP1L1-PDGFRA rearrangement. The patient was treated for FIP1L1-PDGFRA clonal hypereosinophilic syndrome with associated eosinophilic myocarditis and intracardiac thrombus. The treatment regimen consisted of a steroid taper, imatinib, and anticoagulation. Treatment was followed by normalization of the eosinophil count. At two-year follow-up, the patient was without recurrence of eosinophilia on maintenance imatinib and indefinite anticoagulation with warfarin.

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Behçet's disease is a systematic, inflammatory disorder affecting vessels of all sizes. It affects both venous and arterial systems. Vascular involvement carries a high risk of morbidity and mortality. Knowing that Behçet's disease is the most common vasculitides that causes pulmonary artery aneurysms, with a mortality rate of around 25%, makes early detection crucial. Thrombosis in Behçet's disease is mainly caused by an inflammatory process rather than a thrombophilic state, thus vascular thrombosis control is achieved with immunosuppressant medications rather than anticoagulants. An exception to the use of anticoagulants in Behçet's disease appears to be due to cerebral venous thrombosis. The occurrence of multiple site thrombosis and aneurysm simultaneously makes the management very challenging, as we will highlight in our case. We present a case of a 31-year-old female patient with many prior hospitalizations due to cerebral venous thrombosis, bilateral pulmonary thrombi, right ventricular thrombus, and right pulmonary artery aneurysm. The patient was diagnosed with Behçet's disease according to the Behçet's Syndrome International Study Group criteria and then managed with the prophylactic low molecular weight heparin, cyclophosphamide, and prednisolone, resulting in significant improvement in the patient's symptoms. Presentation with cerebral venous thrombosis, pulmonary thrombosis, and aneurysm simultaneously is very rare in Behçet's disease. This made this case distinct and challenging in achieving good control of thrombosis and aneurysm simultaneously, which needs close monitoring and a multidisciplinary team to deal with the case.

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Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths and the sixth most commonly diagnosed cancer worldwide due to several common risk factors, including hepatitis C virus (HCV), hepatitis B virus (HBV), and other causes of cirrhosis. In HCC, intrahepatic vascular invasion and a tumor thrombus are commonly observed. However, the extrahepatic spread of the tumor thrombus to the heart via the portal vein, hepatic vein, and inferior vena cava (IVC) is rarely reported and is considered a poor prognostic factor. In addition, rarely, there is a risk of cor pulmonale and thromboembolism of the pulmonary vessels. Our patient also presented with this rare complication of HCC. Our patient's clinical presentation was bilateral pedal edema, moderate ascites, and abdominal discomfort with raised jugular venous pressure. These signs and symptoms are related to an impairment of the right heart caused by intracardiac tumor thrombus metastasis, leading to diastolic dysfunction. Based on these findings, echocardiography and abdominal computed tomography (CT) scan were performed with the definitive diagnosis of hepatocellular carcinoma with tumor thrombus metastases in the hepatic vein, inferior vena cava, and right atrium. The management team agreed on a conservative treatment plan based on the advanced stage of the disease and the high risk associated with aggressive treatment modalities. Unfortunately, on day 7 of admission, the patient died from a possible pulmonary embolism that led to cardiopulmonary arrest. This case underscores the importance of screening patients with a high HCC tumor burden with abdominal ultrasound and echocardiography for early detection and timely management.

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The coronavirus disease 2019 (COVID-19) infection presents with a wild range of clinical manifestations. Increased inflammatory response and thrombotic risk have been described, being pulmonary embolism a potential cause of death in these patients. Pulmonary embolisms with right ventricle thrombus are rare and have higher mortality rates. This case report concerns a rare clinical presentation of a 75-year-old male with a medical history of right renal transplantation 36 years ago, that presented with a ten-day history of asthenia, followed by fever, shortness of breath, and cough since the day before. He was admitted with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pneumonia and respiratory insufficiency. The next morning the patient worsened, he presented with hypotension, tachycardia, severe refractory hypoxemia, and chest pain. Contrast CT showed a massive pulmonary embolism with a right ventricle thrombus, confirmed by an echocardiogram. Anticoagulation and IV fluids were started, and the patient was transferred to the ICU. He developed obstructive shock, so thrombolysis was performed with a full dose of alteplase. The outcome was good with complete recovery. Posterior investigation excluded other causes for pulmonary embolism. The severity of pulmonary parenchymal disease secondary to COVID-19 correlates with thromboembolic complications, which demand a swift response to avoid death. An abrupt deterioration in oxygenation should raise suspicion for PE in COVID-19 patients, and mostly in the presence of hypotension and tachycardia. In our case report, there was a massive pulmonary embolism with a rare right ventricle thrombus that had a good outcome with medical treatment.

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Morbus Adamantiades-Behçet (MAB) is an inflammatory disease typically manifesting with oral and genital aphthosis, erythema nodosum, and vasculopathy, and in only around 2%, cardiac involvement. Its prevalence is usually higher along the historic Silk Road, but rarer in Scandinavia where 0.64-4.9 in 100,000 people are affected. We herein present two Swedish patients with cardiac manifestations of Morbus Adamantiades-Behçet. Along with the intracardial thrombi, which both patients presented with, one patient also had cerebrovascular insults leading to visual field deficits as well as involvement of peripheral nerves. Being of Scandinavian origin and showing uncommon symptoms as their initial manifestations of MAB, the 62- and 35-year-old patients presenting herein constitute rare cases.

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Biventricular thrombi are a rare clinical entity and only reported in several case reports. Given ventricular thrombi are high risk for cardioembolic events, accurate detection and therapeutic management has an important influence on clinical outcomes. We present a case of a patient with biventricular thrombi that was initially diagnosed on computed tomography angiography, emphasizing its clinical utility as a rapid, non-invasive imaging modality for early detection.

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The factors associated with cerebral infarction and mortality in patients hospitalized with intracardiac thrombus are unknown. A retrospective cohort study was undertaken of nationally representative hospital admissions in the National Inpatient Sample with a diagnosis of intracardiac thrombus between 2016 to 2019. Multiple logistic regressions were used to define factors associated with cerebral infarction and in-hospital mortality. There were a total of 175,370 admissions for patients with intracardiac thrombus and 10.1% patients had cerebral infarction (n = 17,675). Intracardiac thrombus represented 4.4% of primary diagnosis for admissions while circulatory conditions (65.4%), infection (5.9%), gastrointestinal conditions (4.4%), respiratory conditions (4.4%) and cancer (2.2%) were the other prevalent primary diagnoses. All-cause mortality was higher for patients with cerebral infarction (8.5% vs 4.8%). The five factors most associated with cerebral infarction were nephrotic syndrome (OR 2.67 95%CI 1.05-6.78), other thrombophilia (OR 2.12 95%CI 1.52-2.95), primary thrombophilia (OR 1.99 95%CI 1.52-2.53), previous stroke (OR 1.61 95%CI 1.47-1.75) and hypertension (OR 1.41 95%CI 1.27-1.56). The strongest independent predictors of death were heparin induced thrombocytopenia (OR 2.45 95%CI 150-4.00), acute venous thromboembolism (OR 2.03 95%CI 1.78-2.33, p < 0.001) acute myocardial infarction (OR 1.95 95%CI 1.72-2.22), arterial thrombosis (OR 1.75 95%CI 1.39-2.20) and cancer (OR 1.57 95%CI 1.36-1.81). Patients with intracardiac thrombus are at risk of cerebral infarction and in-hospital mortality. Nephrotic syndrome, thrombophilia, previous stroke, hypertension, and heparin induced thrombocytopenia were associated with cerebral infarction, while acute venous thromboembolism, acute myocardial infarction, and cancer were predictors of mortality.

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Intracardiac thrombosis and/or pulmonary thromboembolism (ICT/PE) is a rare but devastating complication during liver transplantation. Its pathophysiology remains poorly understood, and successful treatment remains a challenge. This systematic review summarizes the available published clinical data regarding ICT/PE during liver transplantation. Databases were searched for all publications reporting on ICT/PE during liver transplantation. Data collected included its incidence, patient characteristics, the timing of diagnosis, treatment strategies, and patient outcomes. This review included 59 full-text citations. The point prevalence of ICT/PE was 1.42%. Thrombi were most often diagnosed during the neohepatic phase, particularly at allograft reperfusion. Intravenous heparin was effective in preventing early-stage thrombus from progressing further and restoring hemodynamics in 76.32% of patients it was utilized for; however, the addition of tissue plasminogen activator or sole use of tissue plasminogen activator offered diminishing returns. Despite all resuscitation efforts, the in-hospital mortality rate of an intraoperative ICT/PE was 40.42%, with nearly half of these patients dying intraoperatively. The results of our systematic review are an initial step for providing clinicians with data that can help identify higher-risk patients. The clinical implications of our results warrant the development of identification and management strategies for the timely and effective treatment of these tragic occurrences during liver transplantation.

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