Embolic Manifestations Research Articles

Repeated acute coronary syndrome caused by a mind-bending mural thrombus in ascending aorta: a case report and review of the literature

BackgroundAcute coronary syndrome due to coronary artery embolism in the setting of ascending aortic thrombus is an uncommon condition, even rarer when there is no aortic pathology such as aneurysm, severe atherosclerosis, aortic dissection, or thrombophilia (whether inherited or acquired).Case presentationWe report a case of a 58-year-old male presented with acute chest pain, electrocardiogram showing non-ST-elevation acute coronary syndrome. The computed tomography angiography of coronary artery revealed a mural thrombus in the proximal part of ascending aorta, located above the left coronary artery ostium, without any aortic pathologies. With the exception of hypertension and cigarette smoking, no other risk factors were identified in this patient that may increase the risk of thrombosis. Given the life-threatening risk of interventional therapy and surgery, the patient determinedly opted for anticoagulant and dual antiplatelet therapy. Then he experienced the reoccurrence of chest pain after 6-day treatment, progressed to anterior and inferior ST-segment elevation myocardial infarction. Coronary artery embolism originating from the ascending aortic thrombus was suspected. Considering the hemodynamic instability of the patient, the medical treatment was continued and bridged to warfarin and aspirin after discharge. Follow-up computed tomography angiography at 6 months showed no obstruction in coronary artery and complete resolution of the thrombus. No thromboembolic events occurred henceforward.ConclusionsAcute coronary syndrome could be a manifestation of secondary coronary embolism due to ascending aortic thrombus. Currently, there is no standardized guideline for the treatment of aortic mural thrombus, individualized treatment is recommended. When surgical therapy is not applicable for the patient, anticoagulation and dual antiplatelet treatment are alternative treatments that may successfully lead to the resolution of the aortic thrombus.

Atypical Presentation of Pulmonary Embolism Masquerading as Abdominal Pain

This case report presents a rare manifestation of pulmonary embolism (PE) with atypical abdominal pain, highlighting the diagnostic challenges encountered. A female patient in her early eighties initially presented with left upper abdominal pain, initially treated for Urinary Tract Infection (UTI), and later accurately diagnosed with PE through Computed Tomography Pulmonary Angiography (CTPA). Various mechanisms of abdominal pain in PE are discussed, including right-sided heart failure-induced hepatic congestion and diaphragmatic irritation from pulmonary lobe infarction. Despite dyspnea and chest pain being more common, abdominal pain is documented in 6.7% of cases. This case underscores the importance of considering PE in the differential diagnosis of abdominal pain, particularly in the elderly population, to prevent potentially fatal consequences.

Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report

BackgroundIsolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. Case ReportA 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. Why Should an Emergency Physician Be Aware of This?Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.

Asymptomatic bradycardia as a manifestation of intermediate high-risk pulmonary embolism

Progressively worsening dyspnea as an initial manifestation of an intermediate high-risk pulmonary embolism (PE) is a readily reported life-threatening cardiac emergency. Atypical presentation of PE may make the initial diagnosis challenging and is often the reason it is missed by clinicians. A 60-year-old woman with asymptomatic bradycardia presented with shortness of breath and dizziness. On examination, she was noted to have a heart rate of 40 beats per minute (bpm) which slightly improved to 55 bpm after intravenous (IV) fluids were administered. A transthoracic echocardiogram (TTE) showed evidence of severe right ventricular strain. Chest computed tomography angiogram (CTA) confirmed PE. After percutaneous aspiration thrombectomy, she was transitioned to direct oral anticoagulant (DOAC) from a heparin infusion and discharged on oral anticoagulation. Notably, her hospital course was marked by labile cycles between normotension and hypertension, with blood pressures exceeding 200/100 mmHg. The possibility that hypertensive states may prevent hemodynamic deterioration and a resulting high-risk pulmonary embolism is considered in patients presenting with multiple risk factors for thromboembolism.

Pulmonary embolism masked by symptoms of mental disorders.

The objective of this article is to draw attention to an unusual clinical manifestation of pulmonary embolism (PE) as symptoms suggesting an underlying mental disorder. This seems all the more important since PE is one of the most common causes of potentially preventable hospital deaths and delayed diagnosis of PE in patients consulted at emergency departments has been shown to be most common in elderly patients and the ones presenting with significantly altered mental status. PE is a life-threatening condition that requires prompt diagnosis and appropriate management. There is no symptom that can be found characteristic for PE. Clinical picture of this condition is varied and may resemble many other disorders. The article emphasises that PE may also manifest with psychopathological symptoms that mimic psychiatric emergencies. Three most common groups of psychopathological symptoms that can mask a developing PE, such as panic attacks, symptoms of psychosis, and catatonia, are discussed here based on the literature review. Particular care must be exercised while evaluating such a patient because initial misdiagnosis results in the patient being referred to a mental health care unit instead of a unit treating somatic disorders. There are no diagnostic or treatment facilities in large psychiatric hospitals to assist such a patient. This, in turn, leads to a significant delay in management and, consequently, to major complications or death.

Native-valve endocarditis detected by point-of-care echocardiography

BackgroundInfective endocarditis carries a high morbidity and mortality; therefore, a rapid diagnosis and timely treatment is crucial to improve outcomes. Diagnosis of infective endocarditis is supported on echocardiogram findings.Case presentationAn adult male with history of long-term hemodialysis, presented with embolic manifestations (cerebral, skin) and fever. A large vegetation in the mitral valve and other in the tricuspid valve were detected by point-of-care transthoracic echocardiogram, while blood cultures subsequently resulted positive for methicillin-resistant Staphylococcus aureus. Despite therapeutic efforts, the patient developed into an irreversible shock and died.ConclusionsPoint-of-care echocardiogram has a pivotal role in diagnosis and decision-making of infective endocarditis.

Cerebral Fat Embolism After a Fall

BackgroundCerebral fat embolism is a rare diagnosis that can occur after significant long bone trauma. Most patients have evidence of pulmonary involvement, but this case involved a patient with a pure neurologic manifestation of a fat embolism. Case ReportAn 89-year-old woman presented to the emergency department as a transfer from an outside hospital with a diagnosis of air embolism after an episode of altered mental status and expressive aphasia. A secondary review of the patient's computed tomography angiography head imaging uncovered a cerebral fat embolism as the cause of the patient's acute neurologic event. The cerebral fat embolism was likely from a remote sacral fracture 6 weeks prior. Why Should an Emergency Physician Be Aware of This?When a patient presents with a concern for a stroke-like symptoms and a cerebral fat embolism is diagnosed, a thorough examination of the patient must be performed to identify the primary fracture site. Geriatric long bone fractures have well-known significant morbidity and mortality. An associated cerebral fat embolism can increase that mortality and morbidity and prompt diagnosis is important.

HYPEREOSINOPHILIC SYNDROME WITH INTRACARDIAC THROMBUS PRESENTING WITH EMBOLIC EVENTS

Introduction: Hypereosinophilic syndrome (HES) is a rare disorder characterised by idiopathic eosinophilia with organ system involvement. Its major tissue target is the heart, assuming diverse aspects that affect its different tunics with a varied clinical and echocardiographic expression. Cardiac involvement is frequently associated with ventricular thrombosis, portending a poor prognosis as it can be complicated by acute embolic events, along with the progressive development of restrictive cardiomyopathy, valvular dysfunction, and heart failure. Case Report: We report the case of a 62 years old woman, who presented one month ago a pulmonary embolism, and was admitted for an ischemic stroke related to a ventricular thrombus in the context of a hypereosinophilia syndrome. Conclusion: Embolic manifestations secondary to cardiac involvement may be a mode of revelation of HES. The mortality related to cardiac damage is high, hence the need for appropriate management.

Admission monocyte to high density lipoprotein cholesterol ratio predicts amputation in patients undergoing embolectomy for acute lower extremity ischemia.

Acute limb ischemia is a common clinical manifestation of embolism or thrombosis, which can lead to amputation. Increasing evidence suggests that various biomarkers can predict amputation at the time of admission. Identifying an easily obtainable and inexpensive indicator has always been a major objective. The aim of this study was to determine the predictive value of the admission monocyte count to the HDL-C ratio for a lower extremity amputation in patients undergoing embolectomy for acute limb ischemia. This retrospective, single-center study included 269 patients who underwent an emergent embolectomy. The study population was divided into two groups according to early amputation: the non-amputation group (n = 220) and the amputation group (n = 49). Two groups were compared based on various data. According to the multivariate regression analysis, patients with a higher CRP and MHR have a significantly higher amputation rate (HR: 1.148; CI: 1.075-1.225; p < 0.001 and HR: 1.547; CI: 1.003-2.387; p = 0.04, respectively). Patients with arterial back bleeding have a significantly lower amputation rate (HR: 0.106; CI: 0.02-0.558; p = 0.008). Our study demonstrated that preoperative CRP, MHR, and no arterial back bleeding after surgery were found to be independent predictors of amputation as a poor prognostic factor within 30 days after an embolectomy.

McConnel sign, a simple highly specific sign for identification of a frequent, under diagnosed association: pulmonary embolism and syncope

Syncope is a common reason for emergency room visits and hospital admission and, in about one patient out of six it can be a manifestation of pulmonary embolism (PE). The prognosis of this condition is largely dependent on the timing of diagnosis and treatment since early anticoagulation may modify the clinical consequences of PE and further loss of consciousness. In this article, we describe the case of a woman presenting with syncope, who showed at the admission a cardiac ultrasound highly specific cluster of signs of pulmonary embolism. This rapid non-invasive evaluation permitted to identify causal diagnosis and to speed up the clinical process.

Atrial Fibrillation after Rheumatic Heart Valve Surgery: Incidence, Predictors, and Outcomes.

Atrial fibrillation after cardiac surgery (AFACS) impacts 10 to 65% of patients. AFACS is associated with stroke and other systemic embolic manifestations. Patients at our hospital who underwent rheumatic valve surgery procedures including aortic valve replacement (AVR), mitral valve replacement (MVR), AVR with coronary artery bypass grafting (CABG), MVR with CABG, or AVR and MVR with/without CABG were included in this study in the period from 2002 to 2017. In total, 346 patients were included in the current analysis, with a mean age of 51.6 ± 16.1 years, and 51% were males. AFACS was documented in 102 patients (29.9%) .: Univariate predictors of AFACS included age, gender, body mass index (BMI), operation type, left ventricular ejection fraction (EF), left atrial (LA) diameter, previous history of AF, use of aldosterone antagonists more than a month before surgery, use of diuretics more than a month before surgery, length of ICU stay, total length of stay, cross-clamp time more than 90 minutes, pump time more than 120 minutes, postoperative acute kidney injury, left ventricular dimensions.By multivariate analysis, only age (p = 0.028, AOR = 10.6), male gender (p = 0.021, AOR = 3.4), type of surgery (p = 0.034, AOR = 7.12), history of AF (p = 0.018, AOR = : 2.32), BMI (p < 0.001, AOR = 3.91), EF before surgery (p ≤ 0.001, AOR = 3.91), and LA diameter (p = 0.0051, AOR = 18.23) were independent predictors of AFACS. This study identifies risk factors associated with the development of atrial fibrillation after rheumatic valve heart surgery. Older patients, male gender, type of surgery, preoperative AF, BMI, EF before surgery, and LA diameter are independent predictors of AF after cardiac valve surgery.

A rare cause of myocardial infarction - coronary artery embolization by myxoma fragments

Introduction. Myxoma is the most common intracardiac tumor accounting for about 50% of all heart tumors. The symptoms depend on the size of the tumor, its location and mobility. Embolic manifestations of coronary arteries are extremely rare, occurring in about 0.06% of cases, and they are caused by tumor fragments. Case Report. A 54-year-old female patient was admitted for an acute myocardial infarction with ST segment elevation in the inferior leads. Urgent coronary angiography was performed showing no coronary vessel stenosis. In the projection of the left atrium, a mobile mass with partial calcification was registered, which was stained to a lesser extent with a contrast agent. These were nutrient vessels with a typical ?tumor blush? sign. An echocardiographic examination showed a round, inhomogeneous mass in the left atrium, which was fixed to the interatrial septum. The findings were presented to the cardiology team and urgent surgical extirpation was performed. During the follow-up period of two years, the patient was doing well and echocardiographic examination showed a normal finding, without recurrence of the tumor. Conclusion. Acute myocardial infarction in people without risk factors for ischemic heart disease is very rare. The most common cause of this type of acute coronary syndrome is spontaneous coronary artery dissection. Acute myocardial infarction caused by embolization of the coronary artery by myxoma fragments is a rare phenomenon. Echocardiographic examination is the method of choice in the diagnosis of myxoma. The most effective treatment for these patients is surgical resection of the tumor with low operative mortality.

Imaging of Cardiac Device-Related Infection

Cardiac devices are frequently used in different cardiovascular conditions for the purpose of morbidity or mortality prevention. These include cardiac implantable electronic devices (CIED) like permanent pacemakers and implantable cardiac defibrillators, ventricular assistance devices (VADs), left atrial appendage occlusion (LAAO) devices like the Watchman™, atrial and ventricular septal occluders like the Amplatzer™, among others. In the past years, there has been an increase in the development of these devices as a result of a rise in the number of indications for implantation, paired with the aging and more medically complex patient population. This has led to an increase in the incidence of cardiac device-related infections, one of the most feared and serious complications which is associated with significant morbidity, mortality and financial burden. Accurate diagnosis of cardiac device-related infections is essential given the management implications which often involve removal of the infected device, removal of other prosthetic material and long-term antimicrobial therapy. Clinical and laboratory data are useful diagnostic tools but multimodality imaging is often necessary. The recently published 2020 European Heart Rhythm Association International Consensus document, which is endorsed by many expert societies, has recommended the use of multimodality imaging for the diagnosis of CIED infections. (1) This allows better disease characterization by identifying abnormal fluid collections and guiding aspiration for both diagnostic and therapeutic purposes (i.e. soft tissue ultrasound and computed tomography), evaluation for local extent of disease (i.e. transesophageal echocardiogram to evaluate for concomitant infective endocarditis), embolic manifestation of disease (i.e. computed tomography and magnetic resonance imaging) and metabolic tissue characterization (positron emission tomography and tagged white blood cell scan). (2) In addition, computed tomography (CT) allows for pre-procedural planning which has shown to be associated with better procedural outcomes.

Clinical outcomes of patients with mitral prosthetic valve obstructive thrombosis treated with streptokinase or tenecteplase

Agent of choice for thrombolytic therapy (TT) in prosthetic valve thrombosis (PVT) is unknown. 84 mitral obstructive-PVT episodes treated with TT (43: Tenecteplase; 41: Streptokinase) were included in this prospective study. The incidence of primary end-point (CCS: complete clinical success, defined as complete or partial hemodynamic success with no complications or surgery) was 84.5% with recurrent PVT as a sole predictor. Bleeding and embolic manifestations were noted in 8.3% and 4.7% of episodes respectively. Tenecteplase use was associated with lower complication rate and a mitral EOA of <0.74 cm2 at presentation predicts the need for extended thrombolysis (accuracy, 78.6%).

Thrombocytopenia as First Manifestation of Acute Massive Pulmonary Embolism

Thrombocytopenia as First Manifestation of Acute Massive Pulmonary Embolism

Syncope in Acute Pulmonary Embolism. Importance of Early Recognition of Recurrent Syncope as a Manifestation of Acute Bilateral Pulmonary Embolism

A 43-year-old female patient with past medical history of superficial DVTs, nicotine dependency, and morbid obesity presented with shortness of breath and syncope. She was found to be tachycardic with elevated D-Dimer. Emergent chest-CT was performed which revealed large bilateral pulmonary emboli. As her vitals were within normal limits at that time, there were no indications for tissue plasminogen activator. Later, patient started having fleeting episodes of bradycardia and hypotension with drop in systolic pressure over 40mmHg on slight movements. Being in a rural hospital with limited resources, the decision was made to transfer the patient. Following the transfer, the patient was pronounced deceased due to complications related to her condition. We report this case to emphasize the importance of early recognition and management with thrombolytic therapy or mechanical thrombectomy if contraindications exist in patients with recurrent syncope in a rural setting.

Gastrointestinal and thromboembolic manifestations in COVID-19 Patients: An imaging review

While coronavirus disease 2019 (COVID-19) predominantly involves the respiratory system, it is increasingly recognized that the infection is not restricted to pulmonary system only but other organs are also affected to varying degrees of severity. Gastrointestinal, neurological and cardiac manifestations are reported in addition to dysfunction of hepatic, renal, hematological systems. The wide range of clinical presentations involving multiple organ systems necessitate investigating the causal and association factors of COVID-19 infection. Prompt recognition of the symptoms is necessary for selection of appropriate diagnostic methods and confirmatory tests to reduce delay in initiating the therapy. This manuscript aims to review the spectrum of clinical and imaging aspects of gastrointestinal and thrombo embolic manifestations of COVID-19. Keywords: coronavirus; COVID-19; SARS-CoV-2; gastrointestinal manifestations; thromboembolism

Seizures as the first clinical manifestation of acute pulmonary embolism: an underestimate issue in neurocritical care.

The aim of the present review is to analyze the clinical characteristics of patients with acute pulmonary embolism (PE) which seizures were the first clinical manifestation of the disease. After screening 258 articles in PubMed, Scopus, Cochrane Library, and Google Scholar databases, we identified 16 case reports meeting the inclusion criteria. The mean age of the population was 48.4 ± 19.8years (9 males and 7 females). About three of four patients (68.7%) were hemodynamically stable at admission, having a systolic blood pressure > 90mmHg. Intriguingly, the doubt of acute PE was based on clinical suspicion or on instrumental findings in 62.5% and 18.7% of patients, respectively. In 3 subjects (18.7%), the acute cardiovascular disease was not suspected. Half of patients had an unremarkable previous medical history while neurological comorbidities were present in 4 patients (25.0%). During seizures, a transient loss of consciousness (TLOC) was reported in 6 cases. Seizures were retrospectively classified according to the 2017 ILAE classification, whenever possible. A focal and generalized onset was reported in 37.5% and 50% of cases, respectively, in 12.5% of patient's data that were insufficient to classify the events. The mean number of seizure episodes in the population enrolled was 2.0 ± 1.1. Mortality rate was 54.5% but one investigation did not report the patient's outcome. The relationship between seizures and acute PE is probably underrecognized. Identifying patients that have a high probability of acute PE is fundamental to avoid any treatment delay and ameliorate their outcomes.

P854 The role of multimodality imaging in revealing a rare cause of persistent ascites

Abstract Primary cardiac tumors are very rare causes of intracavitary masses, about 5% of all cardiac tumors. Most of them are benign tumors, and 50% are represented by atrial myxomas. They are usually developed in the left atrium, with a pedicle attached to the interatrial septum. Cardiac myxomas are one of the "greatest mimes" of pathology, with a polymorphic clinical presentation, from obstructive, to embolic and constitutional clinical manifestation. We present the case of a 58-year-old female patient with 4 years history of chronic obstructive pulmonary disease (COPD), on bronchodilator treatment and long-term oxygen therapy. She accused two months duration of abdominal distension due to ascites, for which she was evaluated in the gastroenterology department and received diuretics association. The symptoms were refractory to the treatment, so the patient was referred for cardiovascular examination. At presentation, the patient was afebrile, with a heart rate of 100/minute, blood pressure was 125/90 mmHg. Cardiovascular examination did not reveal any murmurs, jugular venous distension was present. 12-lead electrocardiogram (ECG): sinus rhythm, with right atrial enlargement. The transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) revealed a lobulated giant mass in RA, which occupied almost the entire cavity, with prolapse towards the right ventricle during diastole. Due to the large intracavitary mass, the point of attachment could not be ascertained. Computed tomography (CT) of the thorax was performed and it confirmed the presence of the giant right cardiac mass. The patient underwent surgical excision of the tumor under cardiopulmonary bypass. Intraoperative findings were represented by a yellowish-brown lobulated friable mass in the right atrium cavity, measuring 70/30/35 mm. The pedicle of the tumor was inserted on the free wall of the right atrium. The histopathological examination revealed round to stellate cells in a myxoid stroma, specific for cardiac myxoma. Postoperative evolution was influenced by the severe pulmonary disease, with prolonged mechanical ventilation and positive inotropic support, but it was slowly favorable, and the patient was discharged in good condition. Right atrial myxoma is a very rare intracardiac tumor with nonspecific forms of clinical presentations, that create difficulties in diagnosis. Ascites represents an unusual form of manifestation in a patient with a cardiac tumor. The insertion of the pedicle of the myxoma was atypical and induced difficulties in early evaluation of the tumor type. Even though myxomas are mainly benign tumors, the complication rate is very high, especially of embolic events due to the friable tumoral mass, so they can become life threatening conditions. Early diagnosis of cardiac myxoma based on multimodality imaging is essential, leading to optimal surgical management, with good long-term survival. Abstract P854 Figure. TEE view of giant RA tumor

Left-ventricular thrombus with embolic manifestations in primary antiphospholipid antibody syndrome (P-APLAS): An interesting case of acute cerebral and limb ischemia

Left-ventricular thrombus with embolic manifestations in primary antiphospholipid antibody syndrome (P-APLAS): An interesting case of acute cerebral and limb ischemia