Thrombus Embolization Research Articles

Sirtuin 5 promotes arterial thrombosis by blunting the fibrinolytic system.

Arterial thrombosis as a result of plaque rupture or erosion is a key event in acute cardiovascular events. Sirtuin 5 (SIRT5) belongs to the lifespan-regulating sirtuin superfamily and has been implicated in acute ischaemic stroke and cardiac hypertrophy. This project aims at investigating the role of SIRT5 in arterial thrombus formation. Sirt5 transgenic (Sirt5Tg/0) and knock-out (Sirt5-/-) mice underwent photochemically induced carotid endothelial injury to trigger arterial thrombosis. Primary human aortic endothelial cells (HAECs) were treated with SIRT5 silencing-RNA (si-SIRT5) as well as peripheral blood mononuclear cells from acute coronary syndrome (ACS) patients and non-ACS controls (case-control study, total n = 171) were used to increase the translational relevance of our data. Compared to wild-type controls, Sirt5Tg/0 mice displayed accelerated arterial thrombus formation following endothelial-specific damage. Conversely, in Sirt5-/- mice, arterial thrombosis was blunted. Platelet function was unaltered, as assessed by ex vivo collagen-induced aggregometry. Similarly, activation of the coagulation cascade as assessed by vascular and plasma tissue factor (TF) and TF pathway inhibitor expression was unaltered. Increased thrombus embolization episodes and circulating D-dimer levels suggested augmented activation of the fibrinolytic system in Sirt5-/- mice. Accordingly, Sirt5-/- mice showed reduced plasma and vascular expression of the fibrinolysis inhibitor plasminogen activator inhibitor (PAI)-1. In HAECs, SIRT5-silencing inhibited PAI-1 gene and protein expression in response to TNF-α. This effect was mediated by increased AMPK activation and reduced phosphorylation of the MAP kinase ERK 1/2, but not JNK and p38 as shown both in vivo and in vitro. Lastly, both PAI-1 and SIRT5 gene expressions are increased in ACS patients compared to non-ACS controls after adjustment for cardiovascular risk factors, while PAI-1 expression increased across tertiles of SIRT5. SIRT5 promotes arterial thrombosis by modulating fibrinolysis through endothelial PAI-1 expression. Hence, SIRT5 may be an interesting therapeutic target in the context of atherothrombotic events.

A diagnosis of atrial fibrillation is not a predictor for pulmonary embolism

Background and objectivesAtrial fibrillation causes stroke by embolization of blood clots from the left atrium. This suggests that it also can cause pulmonary embolism through embolization of thrombi from the right atrium. Our objective was to investigate if atrial fibrillation is an independent risk factor for pulmonary embolism. MethodThis is a retrospective registry study of a random sample of 1.5 million Swedish residents alive on January 1, 2010 (n = 1,442,028) who were followed until the end of 2017. Information about comorbidity, medication and outcomes was obtained from the Swedish national health registers. The endpoint was a first-time event of pulmonary embolism. ResultsThe group with atrial fibrillation was >25 years older (mean) than the group without and had almost three times higher incidence of pulmonary embolism (2.91 and 1.09 per 1000 year at risk, p < 0.001). After adjustment for age and other co-factors, atrial fibrillation without oral anticoagulant protection was not associated with increased risk for pulmonary embolism (HR 1.03, CI 0.94–1.13). Adjustment for the competing risk of dying showed similar results (sHR 0.99, CI 0.70–1.40). The higher rate of pulmonary embolism among patients with atrial fibrillation can be fully explained by differences in age and comorbidity. ConclusionA diagnosis of atrial fibrillation is not a predictor for pulmonary embolism.

Fatal cerebral and cardiac infarction due to embolism of a mobile thrombus from aorta sinotubular junction atheroma in a 40-year-old female

Strokes in young adults present a challenging problem in terms of care and social impact. Most of cases in this cohort are classified as strokes of uncertain etiology. Application of multimodality diagnostic approach could help in the estimation of risk factors and underlying mechanisms. Simultaneous acute cardio-cerebral infarction is a rare manifestation, especially in young individuals. Large artery atherosclerosis should be excluded as a potential cause. Transesophageal echocardiography plays an important role in the diagnostic algorithm. The current article presents a clinical case of a fatal acute cardio-cerebral infarction in a 40-year old female without previous cardiovascular diseases and negative family history. Transesophageal echocardiography identified a large mobile thrombus at the sinotubular junction of ascending aorta. Transthoracic echocardiography revealed regional akinesia of the inferior wall, despite normal electrocardiogram. The autopsy findings confirmed co-occurrence of thromboembolic stroke in the right middle cerebral artery area and left ventricular inferior myocardial infarction due to thrombosis of the right coronary artery. This case documents an exceedingly rare phenomenon in this cohort of a cardio-cerebral thromboembolism due to single atherosclerotic plaque destabilization.

Frequency and outcomes of venous thrombus embolism in hospitalized patients with Behçet's disease

Background: Behcet’s Disease (BD) is a multisystem vasculitis characterized by skin-mucosa lesions, ocular, musculoskeletal, gastrointestinal, neurologic, and major vessel involvement. The objective of this present study was to investigate BD in the inpatient setting and the associated risk of contracting venous thrombus embolism. Methods: We utilized the Healthcare Cost and Utilization Project’s National Inpatient Sample (NIS) database. The NIS is the largest inpatient care database in the United States, containing demographic and clinical information from approximately 8 million hospital stays from about 1000 hospitals sampled to approximate a 20% stratified sample of U.S. community hospitals. The 2016 NIS sample utilized ICD-10-CM/PCS diagnostic and procedure codes. Results: The 2016 NIS analysis was performed using 7,135,090 discharge summaries, of which 622 were summaries associated with the ICD-10 code for Behcet's disease (M352). Case discharge summaries were also associated with a slightly longer hospital stay 5.6 days compared to 4.7 days. The percentage of VTE-related ICD codes was 2.8 times higher in case compared to control summaries (P = 4.4e-35). Overall, approximately 1 in 5 case summaries (19.45%) was linked to a VTErelated ICD code, compared to only 6.85% of control summaries. These trends were consistent in analyses performed for each sex separately. Case-male summaries were more frequently associated with VTE-related codes (28.19%) compared to case-female summaries (15.7%). Conclusion: Our study illustrates the association of BD and VTE-related ICD events.

Trombosis venosa profunda en extremidades inferiores: revisión de las técnicas de diagnóstico actuales y su simbiosis con el aprendizaje automático para un diagnóstico oportuno

La Trombosis Venosa Profunda (TVP) es una manifestación de una Enfermedad Tromboembólica (ET). Cuando en una TVP los trombos venosos se desprenden y viajan a través del torrente sanguíneo pueden ocasionar una Trombo Embolia Pulmonar (TEP). La existencia de Trombosis Venosa Profunda (TVP) en las extremidades inferiores se ha descrito como uno de los principales factores de riesgo para el desarrollo de la TEP. Se considera que hasta el 90% de los émbolos pulmonares proceden de trombos venosos de las extremidades inferiores. Las técnicas más utilizadas para la detección de TVP son los modelos de probabilidad clínica, el dímero D y las pruebas de imagen no invasivas, como la ecografía para la TVP y la angiotomografía computadorizada (TC) para el embolismo pulmonar. Sin embargo, debido a la inespecificidad de los síntomas de la TVP, el umbral para ordenar una ecografía es bajo, además de ser un proceso complicado que requiere la participación de un médico especialista para su interpretación. En las últimas décadas el aprendizaje automático ha surgido como apoyo en la toma de decisiones para el diagnóstico de diversas enfermedades, algunas de las tecnologías más utilizadas en el campo de la medicina incluyen Support Vector Machine (SVM), Árboles de decisión y las Redes Neuronales Artificiales (RNA). En el presente artículo se hace una revisión de las tecnologías existentes para la detección de la TVP así como de los principales algoritmos de aprendizaje automático comúnmente utilizados en aplicaciones biomédicas; se propone el diseño de un sistema computarizado que utilice técnicas de aprendizaje automático como herramienta de apoyo para la detección oportuna de un posible padecimiento de TVP.

Safety and Efficacy of Tirofiban During Mechanical Thrombectomy for Stroke Patients with Preceding Intravenous Thrombolysis.

PurposeWhether tirofiban is safe and effective for acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT) with preceding intravenous thrombolysis (IVT) remains unclear. We aim to evaluate the safety and efficacy of tirofiban during MT for patients with preceding IVT.Patients and MethodsPatients who underwent MT and preceding IVT were derived from the ANGEL registry and were dichotomized into tirofiban and non-tirofiban group according to whether rescue tirofiban was performed. The safety endpoints were sICH, total ICH and distal embolization. The efficacy endpoints were arterial recanalization, three-month functional independence (modified Rankin Scale [mRS]: 0–2) and mortality.ResultsWe included 207 MT patients with preceding IVT from the entire registry. Among them, there were 55 in tirofiban group and 152 in non-tirofiban group, and 17 (8.2%) patients suffered sICH and 36 (17.4%) suffered ICH within 24 hours post-MT; 11 (5.3%) distal embolization of thrombus; 111 (53.6%) achieved functional independence and 34 (16.4%) died after three-month follow-up. No significant differences in safety outcomes on sICH, ICH and distal embolization of thrombus and efficacy outcomes on recanalization and long-term functional independence were found between tirofiban and non-tirofiban group for the entire cohort (p>0.05 for all groups). Tirofiban was correlated with long-term mortality reduction for patients underwent MT and preceding IVT (adjusted hazard ratio 0.28 [0.08–0.94], adjusted p=0.03).ConclusionIn AIS patients who underwent MT and preceding IVT, rescue tirofiban was not correlated with increased risk of safety endpoints on sICH, ICH or distal embolization of thrombus, and might be associated with a lower risk of long-term mortality. Further study is needed to confirm the effect of early antiplatelet therapy with tirofiban for patients underwent MT and preceding IVT.

Contrast-Enhanced Ultrasound: Identification of Neovascularization Permits Characterization of Vulnerable Carotid Plaques

Objective: Carotid atherosclerotic vascular disease (ASVD) represents an ongoing health problem and is responsible for a significant proportion of all cerebral ischemic events (CIEs). Method: A review of the literature was performed on the application of contrast-enhanced ultrasound (CEUS) to enhance the diagnosis of ASVD and further avoid CIEs. Results: Cerebral ischemic events are those resulting from reduction or cessation of perfusion to localized regions of the brain made manifest by neurological, typically stroke-like, symptoms. Traditional triplex ultrasound evaluation is a reliable and widely established method of identifying carotid ASVD lesions and grading the accompanying degree of focal stenoses and their hemodynamic impact. While this information plays an integral role in determining management of patients with significant carotid ASVD, it is less useful in classifying individual lesions as “vulnerable” or not. Vulnerable lesions are those that, based on their histological and morphological features, predispose a patient to an increased risk of a CIE due to plaque or thrombus embolization. Conclusions: The addition of CEUS to carotid artery diagnostic studies offers new potential in identifying vulnerable plaques and predicting which patients will progress to sequelae associated with a cerebral ischemic event.

Acute pulmonary embolism and right atrial thrombus as a complication of the central venous access port device for the delivery of chemotherapy.

Acute pulmonary embolism and right atrial thrombus as a complication of the central venous access port device for the delivery of chemotherapy.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Effect of intracoronary tirofiban following aspiration thrombectomy on infarct size, in patients with large anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Myocardial recovery following primary percutaneous coronary intervention is often suboptimal despite of restoration of thrombolysis in myocardial infarction (TIMI) 3 flow, in part due to thrombus embolization which results in impairing microvascular reperfusion besides increasing infarct size. The purpose of the present study was to estimate the effect of aspiration thrombectomy followed by intracoronary delivery of tirofiban on decreasing the infarct size utilizing cardiac MRI (cMR) in large anterior ST-segment elevation myocardial infarction (STEMI) patients. A prospective randomized controlled study of 100 patients with large anterior STEMI were randomized to (Study group) using intracoronary tirofiban (intracoronary) and (control group) without intocoronary tirofiban. A 6 F thrombus aspiration catheter was used in all patients. Tirofiban was injected locally at the place of the highly thrombus burden through the aspiration device after flushing the aspiration device well. Patients of intracoronary tirofiban group compared with control group had a significant difference in decreasing the infarct size at 30 days [median, 15.451 g - interquartile range (IQR), 17.404 gm - n = 50] vs (median, 43.828 g - IQR, 49.599 g - n = 50) P value = 0.002. In patients early presented with large anterior STEMI, infarct size at 30 days was significantly decreased by intracoronary tirofiban delivered to the infarct lesion site followed aspiration thrombectomy.

In Vivo Imaging of Venous Thrombus and Pulmonary Embolism Using Novel Murine Venous Thromboembolism Model

This work established a new murine venous thromboembolism (VTE) model. This model has multiple novel features representing clinical VTE that include the following: 1) deep venous thrombosis (DVT) was formed and extended in the long axis of femoral/saphenous vein; 2) thrombus was formed in a venous valve pocket; 3) deligation of suture-induced spontaneous pulmonary emboli of fibrin-rich DVT; and 4) cardiac motion-free femoral/saphenous vein allowed high-resolution intravital microscopic imaging of fibrin-rich DVT. This new model requires only commercially available epifluorescence microscopy. Therefore, this model has significant potential for better understanding of VTE pathophysiology.

Greenfield stainless steel vena cava filters on computed tomography follow-up

ObjectiveThe objective of this study was to evaluate complications of Greenfield (Boston Scientific, Marlborough, Mass) stainless steel inferior vena cava (IVC) filters on follow-up computed tomography (CT) imaging and to elucidate associated risk factors. MethodsNinety-three patients with CT studies obtained for other reasons after Greenfield IVC filter placement (2007-2014) were retrospectively studied. Greenfield filters were placed permanently in those with venous thromboembolism and an expected lifelong contraindication to anticoagulation or life expectancy <6 months. Patients' demographic data, procedural characteristics, and imaging studies were reviewed and factors associated with perforation rates were analyzed. ResultsA total of 190 follow-up CT imaging studies were available for review. In total, filter-associated IVC thrombus (n = 10 [10.7%]) and pulmonary embolism breakthrough (n = 4 [4.3%)] were documented by contrast-enhanced CT. Perforation was evident in 18 patients (19.4%) with an average indwelling time of 256 days. No symptomatic perforation and no strut fracture were documented. There was no significant difference in perforation rate with respect to age of the patient (P = .61), sex (P = 1.00), or history of malignant disease (P = .40). The filter perforation rate and number of perforating struts were significantly higher in patients with longer indwelling time (>90 days) than in patients with shorter indwelling time (<90 days; P < .01). Caval cross-sectional areas of patients who experienced IVC filter perforations at >90 days were significantly smaller than those of nonperforated patients (284 vs 358 mm2; P < .01). ConclusionsStainless steel Greenfield filters remain a relatively safe option for patients requiring permanent mechanical filtration.

An optimized approach of venous thrombus embolism risk assessment

In this paper, we aim to find new approaches to assess venous thrombus embolism (VTE) risk level. We have obtained valid data by filtering all data relevant to the VTE risk rating which was collected in Shanghai general hospital from May to July 2018. In our research, the distribution rule of the valid data was found and the differences of VTE risk scores before and after the surgery was analyzed via variance analysis. We also explored the correlation between the VTE risk score and inner diameter and flow rate of deep vein in lower extremities. Meanwhile, We build linear model, nonlinear model and ordered multinamial probit model to give out the VTE risk scores. After repeated test,it was concluded that the ordered multinamial probit model was the optimum way in the assessment of VTE risk scores. In short, this paper suggests that surgery has increased VTE risk level which is closely associated with inner diameter and flow rate of deep vein in lower extremities. By deploying ordered multinamial probit model, we are able to assess the VTE risk level. The paper is significant both in theory and the practical application of risk assessment,prevention and treatment of VTE and it is also a theoretical support in VTE risk forecasting for patients with operation in hospital.

P845 Deep vein thrombosis, pulmonary embolism and patent foramen ovale: a lethal mix

Abstract A 50-year-old woman without remarkable medical history was admitted at the Emergency Department for acute dyspnoea. The patient had been recently submitted to C5-C6 microdiscectomy. She was tachypneic and oxygen saturation was 88%. CT angiography showed bilateral pulmonary embolism (PE) (Figure 1A, yellow arrowheads) with signs of right ventricle overload. Bilateral deep vein thrombosis was also confirmed. The patient was admitted at the Intensive Care Unit, clinically stable. Few hours later, she presented sudden hemodynamic and respiratory deterioration, requiring invasive mechanical ventilation and vasopressors. Due to recent cervical surgery, systemic fibrinolysis was ruled out. Decision for percutaneous thrombectomy and inferior vena cava filter placement was made. Nevertheless, percutaneous thrombectomy was unsuccessful due to the impossibility to catheterize pulmonary artery. Contrast injection demonstrated that the guiding catheter was located in the left atrium (Figure 1B), suggesting a patent foramen ovale (PFO). Transoesophageal echocardiogram confirmed the presence of a 5x6 mm PFO with right-to-left shunt (Figures 1C – yellow arrows, and 1D). In addition, a 4 cm mobile mass attached to the aortic valve and protruding throughout the left ventricle outflow tract was visualized, suggesting paradoxical embolism (Figure 1E – white arrows). Accordingly, open surgical approach with pulmonary thrombectomy, PFO closure and removal of the left-sided thrombus was decided. Unfortunately, despite careful cannulation, thrombus was not found when aortic valve was inspected. Worst suspicions were confirmed, when the patient presented non-reactive mydriatic pupils. A brain CT showed signs of an extensive bihemisferic ischemic stroke (Figure 1F) presumably related to cerebral embolization of aortic thrombus. The patient finally died. Autopsy study was not consented. PFO has been associated with paradoxical embolisms and risk of stroke in PE. This case strikingly illustrates that treatment of these patients may be challenging in spite of an adequate diagnosis and management. Abstract P845 Figure.

P689 Surgical treatment of a right heart thrombus-in-transit with massive bilateral pulmonary embolism

Abstract Introduction Right heart thrombi are rare, found in up to 20% of pulmonary emboli (PE), and associated with significantly increased mortality(1). A thrombus entrapped in a PFO is a rare form of right heart thromboembolism. Clinical Case A 73-year-old male patient who had dyspnea for 10 days, was transferred to our hospital for the surgical treatment of a cardiac tumor. We performed TTE which revealed a free floating, huge mass( measuring more than 8 cm long) in the right atrium, that protruded in the right ventricle, with high risk of embolization. Another smaller mass, attached to the interatrial septum. Severe right ventricular dysfunction and severe pulmonary hypertension were present. Contrast-enhanced computer tomography was performed, which revealed severe bilateral pulmonary artery emboli with complete occlusion of right pulmonary artery branch. Clinical and paraclinical data strongly suggested that the huge cardiac mass was a thrombus that originated from the lower extremity veins. TEE showed that the thrombus was entrapped through the PFO, with a smaller part in the left atrium and the biggest portion in the right atrium. The patient underwent an emergent on-pump surgical cardiac and right pulmonary artery embolectomy. The right atrium was opened and a huge intracardiac thrombus with a lengh of 14 cm extending from the coronary sinus, to PFO in the left atrium and also in the right ventricle was removed. The right branch of the pulmonary artery was opened and a large volume of clot- 9 cm long- was removed. The patient was removed from cardio-pulmonary by-pass (CPB) on high doses of norepinephrine and dobutamine and necessitated initiation of venous-arterial ECMO to support the severe right heart dysfunction. He was extubated after 10 days, with little improvement in the clinical status. Transthoracic echocardiography showed smaller right heart cavities), normal left ventricular function, but persistent severe RV dysfunction and severe pulmonary hypertension. In the thirteenth postoperative day, he installed cardio-respiratory arrest and he died. Discussion In this report we describe a case of a patient with a huge intracardiac thrombus, entrapped through a PFO, associated with massive pulmonary embolism, with late presentation in our hospital and severe refractory right heart dysfunction. He underwent successful embolectomy, which is a unique procedure in the treatment of an acute pulmonary embolism and entrapped thrombus in a PFO. Conclusion The treatment of choice for emboli-in-transit is controversial. In a recent review, surgical thromboembolectomy showed a trend toward improved survival and significantly reduced systemic emboli compared to anticoagulation. Thrombolysis in these patients may cause fragmentation of thrombus and systemic embolization, resulting in increased mortality. Management decisions should be made with multidisciplinary coordination and consideration of complicating factors such as PFO. Abstract P689 Figure. Extensive biatrial thrombus

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

P1309 A jellyfish in the sea

Abstract Background The unexpected presence of a left ventricular (LV) mass is always a cause of concern for physicians. This is especially so in the presence of a cerebrovascular accident and a recent cardiac event, where the hunt for a cardioembolic source begins. We describe a case of an unusual presentation of a LV thrombus masquerading as a cystic mass, where diagnosis was confirmed with multimodality imaging tools. Purpose A 58 year old Thai male first presented to the emergency department with left brachio-facial syndrome secondary to a right pre-central gyrus stroke. He had chest pain 2 days prior, and was pain free on admission. An electrocardiogram done showed an evolved anterior myocardial infarction. Methods and Results A transthoracic echocardiogram performed on the 4th day of admission revealed a mildly impaired left ventricular systolic function with an ejection fraction of 45%, and wall motion abnormalities in the left anterior descending artery territory. There was an apical gelatinous-like, cystic and mobile mass with soft flexible walls, measuring 2.4 X 2.1cm. Differentials at this point included cystic thrombus, hydatid cyst, capillary haemangioma and intracardiac tumour. A cardiac MRI was performed which showed an irregular apical mass with features suggestive of fresh thrombus. The mass demonstrates hyperintensity T1-w FSE sequences (with and without fat sat), increased hyperintensity in T2-w triple IR FSE, with no increased uptake in first pass perfusion, T1-w post contrast, or early and late gadolinium enhancement images. A repeat transthoracic echocardiogram done 11 days after anticoagulation showed a 50% reduction in the size of the mass. See images below for more information. Conclusion In the era of early primary percutaneous coronary intervention and anticoagulation following an acute myocardial infarction (AMI), LV thrombus is an uncommon complication. It can occur within 2 weeks after an AMI, where increased blood stasis from dyskinesia or akinesia of associated wall segments, and a hypercoagulable state increases the risk of thrombus formation. A literature search has shown that presentation of the thrombus as a cystic mass is rare as well. As such, early diagnosis allowing for early treatment, especially when systemic embolism of thrombus is suspected, is important. Other causes of cystic LV thrombus do need to be considered in the relevant clinical context. These include infectious causes such as hydatid cyst, capillary hemangioma or intracardiac tumour, which are less likely given the history and investigation results. In this case, a trial of therapy with anticoagulation reduced the size of the cystic mass, and along with imaging findings, confirmed the diagnosis of a cystic LV thrombus. Abstract P1309 Figure. TTE and MRI heart

Manual thromboaspiration as a method of prevention on no-reflow phenomenon

The primary goal of treatment for myocardial infarction with ST-segment elevation (STEMI) is the early restoration of coronary blood flow. However, the restoration of the pathogenesis of the epicardial coronary artery during primary coronary intervention (PPVC) is not always accompanied by normalization of myocardial perfusion, that may be associated with microvascular obstruction and the lack of fusion phenomenon, developing, in particular, due to its long duration of intracoronary thrombus and open distal embolism during PCP. The article is devoted to a review of literature data on predictors of the development of the no-reflow phenomenon and its prevention.

Role of Imaging for Suspected Cardiac Thrombus.

Cardiac thrombus formation is a frequent complication of a variety of prevalent diseases. Embolism of cardiac thrombus has the potential to result in significant morbidity and mortality from cerebrovascular and peripheral vascular events. Echocardiography is the most commonly used imaging modality for diagnosing intracardiac thrombus. However, technological advances in computed tomography and magnetic resonance imaging have allowed newer noninvasive modalities to evolve into robust tools for the clinical evaluation of patients suspected of disease. Complimentary use of these imaging techniques is crucial in the diagnosis of cardiac thrombus and initiation of anticoagulation therapy.

Intraventricular Thrombus Formation and Embolism in Takotsubo Syndrome: Insights From the International Takotsubo Registry.

Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction, which can contribute to intraventricular thrombus and embolism. Still, prevalence and clinical impact of thrombus formation and embolic events on outcome of TTS patients remain unclear. This study aimed to investigate clinical features and outcomes of patients with and without intraventricular thrombus or embolism. Additionally, factors associated with thrombus formation or embolism, as well as predictors for mortality, were identified. Approach and Results: TTS patients enrolled in the International Takotsubo Registry at 28 centers in Australia, Europe, and the United States were dichotomized according to the occurrence/absence of intraventricular thrombus or embolism. Patients with intraventricular thrombus or embolism were defined as the ThrombEmb group. Of 1676 TTS patients, 56 (3.3%) patients developed intraventricular thrombus and/or embolism following TTS diagnosis (median time interval, 2.0 days [range, 0-38 days]). Patients in the ThrombEmb group had a different clinical profile including lower left ventricular ejection fraction, higher prevalence of the apical type, elevated levels of troponin and inflammatory markers, and higher prevalence of vascular disease. In a Firth bias-reduced penalized-likelihood logistic regression model apical type, left ventricular ejection fraction ≤30%, previous vascular disease, and a white blood cell count on admission >10×103 cells/μL emerged as independent predictors for thrombus formation or embolism. Intraventricular thrombus or embolism occur in 3.3% of patients in the acute phase of TTS. A simple risk score including clinical parameters associated with intraventricular thrombus formation or embolism identifies patients at increased risk. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01947621.