Diagnosis Of Thrombus Research Articles

Exclusion of Intra-Atrial Thrombus Diagnosis Using D-Dimer Assay Before Catheter Ablation of Atrial Fibrillation

This study hypothesized that the association of D-dimer blood level and several clinical items in a new risk score could predict the absence of atrial thrombus. Symptomatic and drug resistant atrial fibrillation (AF) can be treated by catheter ablation. The procedure-related risk of thromboembolism is limited by the pre-operative use of transesophageal echocardiography (TEE) to detect atrial thrombi. Patients admitted for catheter ablation of AF (n= 2,494) were prospectively included in a multicenter study. TEE was systematically performed before the procedure to search for atrial thrombus (primary endpoint). D-dimer level, CHADS2 score, left ventricular ejection fraction, pre-operative anticoagulation regimen, and medical history were collected. A logistic regression model was used to identify factors associated with the presence of atrial thrombus (hypertension, history of stroke, heart failure, D-dimer level >270 ng/ml). These factors were aggregated in a new score called atrial thrombus exclusion (ATE). The incidence of atrial thrombus was 1.92%. CHADS2 score and D-dimer level were significantly associated with atrial thrombus (p< 0.0001 and p< 0.0001, respectively). A zero CHADS2 score failed to exclude all atrial thrombi (5 false negatives; sensitivity: 89.58%, specificity: 52.2%). No false negative was found with a zero ATE score, which had a specificity of 37% and a higher sensitivity (100%) than the CHADS2 score (p< 0.031) to predict the absence of intra-atrial thrombi on TEE. Conversely, the positive predictive value was poor, and the ATE score should not be used to conclude a positive diagnosis of thrombus. An ATE score of zero was strongly associated with the absence of atrial thrombus. This new score could be useful to rule out a diagnosis of atrial thrombus before catheter ablation of AF.

Real-time surveillance of left atrial appendage thrombus during contrast computed tomography imaging for catheter ablation: THe Reliability of cOMputed tomography Beyond UltraSound in THROMBUS detection (THROMBUS) study.

Left atrial contrast computed tomography (LA-CT) as well as transesophageal echocardiography (TEE) can exclude left atrial appendage (LAA) thrombus, but is sometimes unable to evaluate LAA due to incomplete LAA filling. The aim of the current study was to validate the utility of real-time approach of LA-CT with real-time surveillance of LAA-filling defect (FD). We enrolled consecutive 894 patients with LA-CT studies acquired for catheter ablation and compared the diagnostic accuracy in demonstrating LAA-FD between conventional protocol (N = 474) and novel protocol with real-time surveillance of LAA-FD immediately after the initial scanning and, when necessary, adding delayed scanning in the supine or prone position (N = 420). Primary endpoint was severity of LAA-FD classified into the 3 groups: "Grade-0" for complete filling of contrast, "Grade-1" for incomplete filling of contrast, and "Grade-2" for complete FD of contrast. The prevalence of Grade-1 and Grade-2 FD was 17.3% and 11.2% in conventional protocol, whereas there was no patient with Grade-2 FD, and only 1 patient with Grade-1 FD after the additional scanning in novel protocol. In 5 patients with suspected LAA thrombus both by TEE and Grade-2 FD in LA-CT by the conventional protocol, ablation procedure was canceled due to diagnosis of LAA thrombus. Conversely, 4 patients with suspected LAA thrombus by TEE in novel protocol group was proved to have intact LAA by LA-CT with and without additional scanning. This novel approach with real-time surveillance improved the diagnostic accuracy of LA-CT in detecting LAA-FD, suggesting potential superiority of LA-CT over TEE in excluding LAA thrombus.

Left Ventricular Thrombus After Acute Myocardial Infarction

ImportanceLeft ventricular (LV) thrombus is a complication of acute myocardial infarction (MI) and is associated with systemic thromboembolism. With randomized clinical trials investigating the optimal antithrombotic regimen in patients with MI who require concomitant chronic anticoagulation and with the emergence of the direct-acting oral anticoagulants, treatment options for post-MI LV thrombus have become more complicated. Herein, we review the epidemiology, pathogenesis, diagnosis, prevention, and treatment of LV thrombus after acute MI.ObservationsContemporary epidemiologic data suggest the incidence of LV thrombus, detected using optimal imaging modalities, may be as high as 15% in patients with ST-segment elevation MI and up to 25% in patients with anterior MI. While a standard transthoracic echocardiogram is commonly used for screening, it is limited by low sensitivity for LV thrombus detection, necessitating the addition of contrast (unless contraindicated) and/or use of cardiac magnetic resonance imaging when pretest probability is high. To our knowledge, there are no existing randomized clinical trials evaluating the safety and efficacy of anticoagulation in the prevention or treatment of LV thrombus after MI, and clinicians must rely on available epidemiologic and trial-generated data from related entities to guide treatment. Randomized clinical trials have confirmed that triple therapy increases bleeding rates compared with less potent antithrombotic regimens after MI, and observational data suggest that triple therapy regimens may not prevent LV thrombus formation. On the other hand, if an LV thrombus is detected, anticoagulation is essential to prevent systemic thromboembolism. We offer 1 approach to treatment, grounded in the best available data.Conclusions and RelevanceUncertainties remain regarding the optimal screening pathway, frequency of follow-up imaging, candidate selection for thromboprophylaxis, and treatment strategies for post-MI LV thrombus. Ongoing studies from related therapeutic areas of varying antithrombotic regimens will continue to inform the optimal approach to treatment; however, more dedicated study of this clinical conundrum is also needed.

IgG4-related disease of pulmonary artery causing pulmonary hypertension.

IgG4-related disease (IgG4-RD) is recognized as an immune-mediated condition with pathology features of lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis, accompanied with or without elevated serum IgG4 concentrations. However, few of pulmonary artery IgG4-RD causing pulmonary hypertension (PH) was reported.The medical records of 3 patients with pulmonary artery IgG4-RD inducing PH were analyzed retrospectively.Imaging findings demonstrated that the lesions of 3 patients located in pulmonary artery, which were initially diagnosed as pulmonary thrombus or malignant tumor. Computed tomography pulmonary angiography (CTPA), ultrasonic cardiogram, and positron emission tomography/computed tomography (PET/CT) didn’t support the diagnosis of pulmonary thrombus or malignant tumor. Right heart catheterization (RHC) showed definite PH. Biopsy by right heart catheterization in 2 patients or pneumonectomy in 1 patient confirmed the diagnosis as IgG4-RD. Treated with glucocorticoids and cyclophosphamide or rituximab, 2 patients’ IgG4 concentrations declined sharply and the lesions shrunk gradually. Another patient treated with glucocorticoids died of heart failure.IgG4-RD involved pulmonary artery causing PH was rare. A high index of awareness of this disease is required for early diagnosis and treatment. PET/CT might be a valuable approach to distinguish pulmonary artery IgG4-RD from pulmonary thrombus and malignant tumor.

Application of OPT101 sensor in ICU-specific near-infrared spectroscopy instrumentation

The OPT101 photoelectric sensor has the characteristics of good photoelectric response, built-in transimpedance amplifier and small size, which meet the needs of accurately near-infrared spectral measurement in medical near-infrared spectroscopy (NIRS) range. Our research team has developed a series of portable NIRS instruments for NIRS measuring in intensive care units (ICU). The characteristics and advantages of OPT101 in the development of clinical ICU-specific NIRS instruments were introduced. The research progress of our team on the development of ICU-NIRS instruments using OPT101 was reviewed. The prospect of OPT101 in clinical noninvasive detection was discussed. Key words: Optoelectronic sensor; Near-infrared spectroscopy; Thrombus diagnosis; Shock monitoring; Fatigue evaluation

Role of FDG PET-CT in Distinction of Benign Thrombus and Tumor Thrombus in Oncological Patients

Accurate diagnosis of tumor thrombus and distinguishing benign thrombus from tumor thrombus avoid unnecessary anticoagulant...

Small molecule metabolite biomarkers for hepatocellular carcinoma with bile duct tumor thrombus diagnosis

Hepatocellular carcinoma with bile duct tumor thrombus (BDTT) is a malignant disease. The most commonly used diagnosis methods for BDTT are MRCP/ERCP, ultrasonic diagnosis or CT scan. However, BDTT is often misdiagnosed as other bile duct diseases, such as extrahepatic cholangiocarcinoma (EHCC), choledochal cyst (Cyst) and common bile duct stone (Stone). Diagnostic methods, which are more accurate and less destructive, are urgently needed. In this paper, we analyzed the small molecule metabolites in the serum of BDTT, Stone, Cyst and EHCC patients and normal people using untargeted GC-MS, and identified 21 metabolites that show different levels among different samples. Using targeted UHPLC-QQQ-MS analysis, we found that several metabolites are significantly changed. ROC curve analysis revealed two metabolites, L-citrulline and D-aspartic acid, as potential biomarkers that can distinguish BDTT from other bile duct diseases.

Transesophageal echocardiography for the assessment of left atrial appendage thrombus: Study of the additional value of systematic real time 3D imaging after regular 2D evaluation.

Two-dimensional transesophageal echocardiography (2DTEE) is currently validated for left atrial appendage (LAA) thrombus assessment but has some limitations. To evaluate the performance and interest of systematic real time three-dimensional transesophageal echocardiography (3DTEE) for LAA thrombus assessment, when performed after 2DTEE. Consecutive patients undergoing TEE were prospectively included. LAA was first evaluated using 2DTEE, and patients were classified as "2D-NT" if no thrombus was found, "2D-T" in case of clear thrombus, or "2D-EQ" if equivocal. Then, 3DTEE of the LAA was performed and patients were similarly classified as "3D-NT," "3D-T," or "3D-EQ." Additional LAA CT scan was only performed if LAA thrombus was not clearly ruled out or confirmed by TEE. Additional value of 3DTEE after 2DTEE LAA evaluation was then assessed. We included 104 patients undergoing TEE. Agreement between 2DTEE and 3DTEE was very good for thrombus diagnosis (k=0.936), but moderate for vacant LAA (k=0.562) due to more frequent 2D-EQ than 3D-EQ (11.5% vs 2.9%; P=.016). 3DTEE allowed to refine the LAA status in 11 of 12 (91.7%) 2D-EQ patients: 10 3D-NT, 1 3D-T, and 1 3D-EQ. Coupling 3DTEE to 2DTEE permitted a definite LAA diagnosis in 103 of 104 (99%) vs 92 of 104 (88.5%) patients when 2DTEE was used alone (P=.002). Nine (8.7%) LAA thrombi were diagnosed, and 3 CT scan were performed. 3DTEE of the LAA is more effective for thrombus assessment than 2DTEE. 3DTEE should be particularly considered in case of equivocal 2DTEE, as it allows to reach a definite LAA diagnosis in almost all of the patients.

Diagnosis and treatment of a large left atrial thrombus: a case report

Diagnosis and treatment of a large left atrial thrombus: a case report

Clinical study of optical coherence tomography in the diagnosis of peripheral pulmonary artery thrombus

BackgroundPeripheral pulmonary artery thrombus (PPT) is common in the clinic. However, due to the lack of an ideal diagnostic tool, PPT cannot be quickly diagnosed and effectively treated at present. Optical coherence tomography (OCT) is a new intravascular imaging technique that is characterized by high image resolution. This technique is suitable for small vessel imaging and has the ability to distinguish red and white thrombi. ObjectiveThis study aimed to evaluate the value of OCT in the diagnosis of PPT and in identifying the nature of thrombi by comparing the difference in sensitivity between OCT and selective pulmonary angiography (SPA). MethodsHighly suspected PPT patients were enrolled in this study. Pulmonary ventilation/perfusion (V/Q) mismatch pulmonary segments or peripheral pulmonary arteries were chosen. SPA was performed first, followed by OCT imaging. The diagnostic standard of thrombus with SPA was an intraluminal filling defect. The procedure and criteria for OCT diagnosis of thrombus were previously introduced in intracoronary OCT thrombus images. The diameter of the imaging vessels was measured, and they were grouped according to diameter. The diameter was <2mm in the distal segment group, 2–3mm in the middle segment group, and >3mm in the proximal segment group. The recognition abilities of intravascular thrombus with the different diameters of these two techniques were compared. Patients with obvious clinical symptoms and more red thromboses revealed by OCT were given standardized anticoagulant therapy for half a year. The clinical symptoms, 6-minute walking test and changes in the thrombus in the OCT images of these patients before and after treatment were observed. ResultsA total of 22 patients with highly suspected PPT were suggested to undergo V/Q inspection. Finally, 12 patients were eligible for the study. SPA and OCT were performed in 61 peripheral pulmonary arteries in all 12 patients. The ideal SPA and OCT images obtained from a total of 76 blood vessel segments were suitable for comparative analysis. A total of 62 thrombi were found by SPA. Among these, eight thrombi were in the distal segment, 29 thrombi were in the middle segment, and 25 thrombi were in the proximal segment. A total of 81 thrombi were found by OCT, among which 22 thrombi were in the distal segment, 31 were in the middle segment, and 28 were in the proximal segment. There was a significant difference between two groups in the distal segment group (P=0.013), while there was no significant difference between two groups in the middle segment group or the proximal segment group (P>0.05). In addition to all the thrombi found by SPA, OCT found other thrombi that were missed by SPA. According to previous OCT images for determining the nature of thrombi, OCT revealed 81 thrombi, of which 48 (59%) were red thrombi and 33 (41%) were white thrombi. Then, seven patients who had obvious clinical symptoms and more red thrombi in the peripheral pulmonary artery were given anticoagulant therapy for six months. After treatment, these symptoms were improved, oxygenation indexes increased, and the six-minute walking test was extended in all these patients. After anticoagulation therapy, five patients underwent OCT review. These OCT images were matched and compared before and after anticoagulation therapy. The results revealed that most of the thrombi had disappeared, and a small amount of red thrombi turned white as the volume reduced. The mean lumen area before and after treatment was 2.05±1.03mm2 and 2.86±1.24mm2, respectively, and the difference was statistically significant (P=0.035). ConclusionOCT can clearly show the structure of the lumen and the wall of the peripheral pulmonary artery tube. The sensitivity of the diagnosis of PPT with a diameter of <2mm was higher than that of SPA. Moreover, OCT has the ability to distinguish between red and white thrombi, which is of guiding significance in anticoagulant therapy.

Incidence of Left Ventricular Thrombus in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated with Percutaneous Coronary Intervention

Previous studies using 2-dimensional non-contrast echocardiography have reported a post-ST segment elevation myocardial infarction (STEMI) left ventricular (LV) thrombus incidence of 3% to 24%. However, these studies were not performed with ultrasound contrast agents (UCAs), which improve accuracy in the diagnosis of LV thrombus. We aimed to determine the early incidence and clinical correlates of LV thrombus in a large consecutive cohort of patients with STEMI. This study included consecutive patients admitted to Saint Luke's Mid America Heart Institute with STEMI who also underwent early percutaneous coronary intervention (PCI) and an echocardiogram. A total of 1,698 patients (1,205 men, mean age 61 ± 13 years) comprised the study group. Echocardiography was performed on hospital day 2, and a UCA was used in 1,292 patients (76%). LV thrombus was identified in 28 (1.6%) patients. A multivariable logistic regression model showed that left anterior descending intervention was independently associated with LV thrombus (odds ratio = 7.58, 95% confidence interval [CI] 2.20 to 26.19, p = 0.001), thrombolysis in myocardial infarction III flow was marginally associated with less LV thrombus (odds ratio = 0.41, 95% CI 0.16 to 1.04, p = 0.060), and higher LVEF was associated with less LV thrombus (odds ratio = 0.96, 95% CI 0.91 to 0.97, p <0.001). In conclusion, LV thrombus was identified in only 1.6% of patients in a large STEMI cohort, significantly lower than previous studies. A UCA was used in most echocardiograms, and it improves accuracy in the detection and exclusion of LV thrombus.

Venous invasion by hepatic tumors: imaging appearance and implications for management.

Venous invasion by hepatic tumors most commonly occurs with hepatocellular carcinoma and is associated with worse patient prognosis. Imaging plays an important role in the diagnosis of tumor thrombus in the liver. Moreover, differentiating between bland and tumor thrombus in the liver has important diagnostic, staging, therapeutic, and prognostic implications and may require a multimodal imaging approach including ultrasound, computed tomography, and/or magnetic resonance imaging. Treatment of hepatic malignancies with associated tumor thrombus is dependent on tumor type, disease extent within the liver, liver hemodynamics, and underlying liver function. Treatment of such tumors may involve surgical, locoregional and/or systemic therapies. The current review will focus on the imaging characteristics of venous invasion by hepatic tumors. The imaging findings most useful for differentiating hepatic venous tumor thrombus and bland thrombus will be highlighted and demonstrated with imaging examples. Imaging findings with implications for subsequent patient management will be described.

Diagnosis and treatment of renal cell carcinoma complicated with inferior vena cava tumor thrombus in hepatic segment and upper hepatic segment

Surgical treatment is the only cure treatment for patients with inferior vena cava tumor thrombus in hepatic segment and upper hepatic segment. The accurate diagnosis of tumor thrombus is very important. In preoperative imaging examination, the abdominal enhanced CT scan and the inferior vena cava MRI scan were the best methods for the diagnosis and evaluation of the tumor thrombus in hepatic segment and upper hepatic segment. Compared with the tumor thrombus below the liver, the tumor thrombus in hepatic segment or above hepatic segment extend widely, and the operation are more difficult. For simple inferior vena cava tumor thrombus (the top of the thrombus has reached the level of hepatic vein), Retroperitoneal approach combined with transperitoneal approach should be used. Open surgery is the standard procedure for other tumor thrombus in hepatic segment and upper hepatic segment. In addition to exposure of inferior vena cava below the hepatic vein, the liver and the first hepatic hilum should be exposed. For tumor thrombus in the atrium, after the longitudinal incision of diaphragm, we use Milking technology to squeeze thrombus into inferior vena cava. Then we use catheterization technology to remove thrombus. For difficult atrial tumor thrombus, an extracorporeal circulation should be performed. The median incision in the chest should be performed to open the chest and open the pericardium and remove the tumor thrombus. Patients with tumor thrombus in hepatic segment or upper hepatic segment should be diagnosed as early as possible and they need actively treated by operation. Key words: Renal carcinoma; Tumor thrombus; Inferior vena cava; Hepatic segment

Organic Semiconducting Nanoparticles as Efficient Photoacoustic Agents for Lightening Early Thrombus and Monitoring Thrombolysis in Living Mice.

Acute venous thrombosis is prevalent and potentially fatal. Accurate diagnosis of early thrombus is needed for patients in timely clinical intervention to prevent life-threatening conditions. Photoacoustic imaging (PAI) with excellent spatial resolution and high optical contrast shows more promise for this purpose. However, its application is dramatically limited by its signal-off effect on thrombus because of the ischemia in thrombus which lacks the endogenous photoacoustic (PA) signal of hemoglobin. To address this dilemma, we herein report the feasibility of using organic semiconducting nanoparticles (NPs) for contrast-enhanced PAI of thrombus in living mice. An organic semiconducting NP, self-assembled by amphiphilic perylene-3,4,9,10-tetracarboxylic diimide (PDI) molecules, is chemically modified with cyclic Arg-Gly-Asp (cRGD) peptides as a PA contrast agent (cRGD-PDI NPs) for selectively lightening early thrombus. cRGD-PDI NPs presents high PA intensity, good stability in light and serum, and sufficient blood-circulating half-life. In living mice, PA intensity of early thrombus significantly increases after tail vein injection of cRGD-PDI NPs, which is 4-fold greater than that of the control, blocking, and old thrombus groups. Pathological and immunohistochemical findings show that glycoprotein IIb/IIIa abundant in early thrombus is a good biomarker targeted by cRGD-PDI NPs for distinguishing early thrombus from old thrombus by PAI. Such a lightening PAI effect by cRGD-PDI NPs successfully provides accurate information including the profile, size and conformation, and spatial distribution of early thrombus, which may timely monitor the obstructive degree of thrombus in blood vessels and the thrombolysis effect.

Incidence, Outcomes, and Predictors of Ventricular Thrombus after Reperfused ST-Segment-Elevation Myocardial Infarction by Using Sequential Cardiac MR Imaging.

Purpose To characterize the incidence, outcomes, and predictors of left ventricular (LV) thrombus by using sequential cardiac magnetic resonance (MR) imaging after ST-segment-elevation myocardial infarction (STEMI). Materials and Methods Written informed consent was obtained from all patients, and the study protocol was approved by the committee on human research. In a cohort of 772 patients with STEMI, 392 (mean age, 58 years; range, 24-89 years) were retrospectively selected who were studied with cardiac MR imaging at 1 week and 6 months. Cardiac MR imaging guided the initiation and withdrawal of anticoagulants. Patients with LV thrombus at 6 months were restudied at 1 year. For predicting the occurrence of LV thrombus, a multiple regression model was applied. Results LV thrombus was detected in 27 of 392 patients (7%): 18 (5%) at 1 week and nine (2%) at 6 months. LV thrombus resolved in 22 of 25 patients (88%) restudied within the first year. During a mean follow-up of 181 weeks ± 168, patients with LV thrombus displayed a very low rate of stroke (0%), peripheral embolism (0%), and severe hemorrhage (n = 1, 3.7%). LV ejection fraction (LVEF) less than 50% (P < .001) and anterior infarction (P = .008) independently helped predict LV thrombus. The incidence of LV thrombus was as follows: (a) nonanterior infarction, LVEF 50% or greater (one of 135, 1%); (b) nonanterior infarction, LVEF less than 50% (one of 50, 2%); (c) anterior infarction, LVEF 50% or greater (two of 92, 2%); and (d) anterior infarction, LVEF less than 50% (23 of 115, 20%) (P < .001 for the trend). Conclusion Cardiac MR imaging contributes information for the diagnosis and therapy of LV thrombus after STEMI. Patients with simultaneous anterior infarction and LVEF less than 50% are at highest risk. © RSNA, 2017 Online supplemental material is available for this article.

Computed Tomography-Based Thrombus Imaging for the Prediction of Recanalization after Reperfusion Therapy in Stroke.

The prediction of successful recanalization following thrombolytic or endovascular treatment may be helpful to determine the strategy of recanalization treatment in acute stroke. Thrombus can be detected using noncontrast computed tomography (CT) as a hyperdense artery sign or blooming artifact on a T2*-weighted gradient-recalled image. The detection of thrombus using CT depends on slice thickness. Thrombus burden can be determined in terms of the length, volume, and clot burden score. The thrombus size can be quantitatively measured on thin-section CT or CT angiography/magnetic resonance angiography. The determination of thrombus size may be predictive of successful recanalization/non-recanalization after intravenous thrombolysis and endovascular treatment. However, cut-offs of thrombus size for predicting recanalization/non-recanalization are different among studies, due to different methods of measurements. Thus, a standardized method to measure the thrombus is necessary for thrombus imaging to be useful and reliable in clinical practice. Software-based measurements may provide a reliable and accurate assessment. The measurement should be easy and rapid to be more widely used in practice, which could be achieved by improvement of the user interface. In addition to prediction of recanalization, sequential measurements of thrombus volume before and after the treatment may also be useful to determine the efficacy of new thrombolytic drugs. This manuscript reviews the diagnosis of thrombus, prediction of recanalization using thrombus imaging, and practical considerations for the measurement of thrombus burden and density on CT.

Technological Improvements in Cardiac Thrombus Diagnosis

Technological Improvements in Cardiac Thrombus Diagnosis

Left atrial appendage function assessment and thrombus identification

BackgroundThe diagnosis of thrombus in the left atrium in patients with persistent atrial fibrillation (AF) and may be inconsistent because of variability in thrombus morphology. In some cases it is challenging and requires unusual approach. New Doppler-derived methods might be helpful to identify such thrombi. We evaluated quantitative differences in mechanical function of the left atrial appendage (LAA) basal segments using tissue Doppler imaging (TDI)and speckle tracking echocardiography (STE) in patients with non-valvular AF with and without LAA thrombus and compared them with SR patients. MethodsA total of 80 patients with normal left ventricular ejection fraction underwent transesophageal echocardiography (40 patients with SR and 40 patients with AF on oral anticoagulants including patients with LAA thrombus). We analyzed the basal segments of LAA including left lateral ridge (LLR) and baso-medial appendage segment (BMAS). Quantitative analysis was used to calculate peak velocity, average velocity, strain, strain rate and deformation. ResultsIn patients with AF the lower LLR strain rate was the sole new STE significant parameter differentiating patients with and without LAA thrombi: −0.9(−1.2; −0.1)s−1 vs. −1.6(−1.9; −1.3)s−1, (p=0.004). Additionally, patients in SR demonstrated significantly better peak velocity, average velocity, strain, strain rate and deformation than those with AF (p<0.001). ConclusionsLLR appeared to be an appropriate site for measuring Doppler derived parameters. It is possible that the strain rate in LLR area may be a novel parameter correlating with the presence of thrombus in patients with AF.

Heparin for the treatment of thrombosis in neonates.

Among pediatric patients, newborns are at highest risk of developing thromboembolism. Neonatal thromboembolic (TE) events may consist of both venous and arterial thromboses and often iatrogenic complications (eg, central catheterization). Treatment guidelines for pediatric patients with TE events most often are extrapolated from the literature regarding adults. Options for the management of neonatal TE events include expectant management; nitroglycerin ointment; thrombolytic therapy or anticoagulant therapy, or a combination of the two; and surgery. Since the 1990s, low molecular weight heparin (LMWH) has become the neonatal anticoagulant of choice. Reasons for its appeal include predictable dose response, no need for venous access, and limited monitoring requirements. The overall major complication rate is around 5%. Whether preterm infants are at increased risk is unclear. No data are available on the frequency of osteoporosis, heparin-induced thrombocytopenia (HIT), or other hypersensitivity reactions in children and neonates exposed to LMWH. To assess whether heparin treatment (both unfractionated heparin [UFH] and LMWH) reduces mortality and morbidity rates in preterm and term newborn infants with diagnosed thrombosis. The intervention is compared with placebo or no treatment. Also, to assess the safety of heparin therapy (both UFH and LMWH) for potential harms.Subgroup analyses were planned to examine gestational age, birth weight, mode of thrombus diagnosis, presence of a central line, positive family history for genetic disorders (thrombophilia, deficiency of protein S and protein C, methylenetetrahydrofolate reductase [MTHFR] mutation), route of heparin administration, type of heparin used, and location of thrombus (see "Subgroup analysis and investigation of heterogeneity"). We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4), MEDLINE via PubMed (1966 to May 9, 2016), Embase (1980 to May 9, 2016), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to May 9, 2016). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. Randomized, quasi-randomized, and cluster-randomized controlled trials comparing heparin versus placebo or no treatment in preterm and term neonates with a diagnosis of thrombosis. We used the standard methods of the Cochrane Neonatal Review Group. Two review authors independently assessed studies identified by the search strategy for inclusion. Our search strategy yielded 1160 references. Two review authors independently assessed all references for inclusion. We found no completed studies and no ongoing trials for inclusion. We found no studies that met our inclusion criteria and no evidence from randomized controlled trials to recommend or refute the use of heparin for treatment of neonates with thrombosis.

Successful pacemaker lead extraction involving an ossified thrombus: A case report

A 41-year-old woman who had been fitted with a pacemaker 18 years prior presented for lead extraction because of device infection. First, we tried laser sheath. However, it cannot cross the binding in the innominate vein. Then we switched to the rotating mechanical sheath. Although it crunched through binding tissue, the progress halted. We removed the sheath and found pieces of calcified tissue in the sheath lumen. After removing the calcified tissue, both leads were extracted using the laser sheath, without complications. The pathological examination revealed a diagnosis of ossified thrombus. Venous thromboses associated with implanted leads can ossify with time, causing difficulties in the extraction of long-standing intravascular leads.