Heart Thrombus Research Articles

O68 ATRIAL SEPTAL ANEURYSM IN IDENTICALS TWINS

Introduction: Interatrial septal aneurysm (ISA) is a dilatation of saccular tissue, generally located in the foramen ovale area, which moves freely and protrudes into the right or left atrium, or even both. Today it is estimated that 85% of children born with congenital heart disease survive to adulthood, however, we have not found cases of ISA reported in identical twins in adulthood. Methods: Two 55-year-old female patients, identical twins EAM and RAM, body surface area 1,899 and 1,826 m2 respectively, consulted for elevated blood pressure (160/90 and 160/95 mmHg respectively). One of them reported headache accompanied by joint pain and mild dyspnea, the other patient reported palpitations and mild dizziness. His parents are hypertensive. They were hospitalized at 5 months of age due to viral meningitis, with no further consequences. Antihypertensive treatment, laboratory, stress test, and echocardiogram/Doppler were prescribed. Results: Laboratory tests were found to be normal. The stress test (protocol: Bruce) was reported to be negative for induced myocardial ischemia. Echocardiography revealed ISA in both patients. Conclusions: Twins, particularly monochorionic twins, are at increased risk of congenital anomalies compared with singleton pregnancies, and the risk of cerebrovascular disease (CVD) or transient ischemic attack (TIA) in patients with ISA is 6.7% in adult patients. ISA has been associated with acquired cardiac diseases, such as valvular heart disease, cardiomyopathies, pulmonary and systemic hypertension, ischemic heart disease, arrhythmias, and thrombus formation. More recently, an association with embolic cerebrovascular pathology has been observed, both in TIA and CVD. For this reason, we consider that in adult patients who are identical twins when one of them is found with ISA, an evaluation should be carried out in their twin for its appropriate treatment and thus avoid future cardiovascular complications derived from this anomaly. According to our reviews, this is the first case of ISA in identical twins. New observations on ISA in twins are needed.

Effectiveness of thrombolytic therapy in patients with severe COVID-19 and pulmonary embolism

Current research provides insufficient data on the use of thrombolytic therapy in the treatment of pulmonary embolism in patients with COVID-19. Existing studies present data on the efficacy of thrombolytic drug therapy for thrombotic complications in severe COVID-19. However, these studies either involve a very small number of observations or remain incomplete. This article aimed to assess systemic thrombolysis’s effectiveness in intravenous alteplase administration in this pathology. The medical records of 92 patients were analysed. Patients were divided into four groups depending on the therapy administered. Patients in the first group had complications in the form of pulmonary embolism but did not require thrombolytic therapy. Treatment of patients in the first group consisted of prescribing low-molecular-weight heparin at a therapeutic dose. Patients in the second and third groups had pulmonary embolism in the context of COVID-19 and required thrombolytic therapy. The third group differed from the second in the presence of a thrombus in the right heart. Patients in the fourth group had complications in the form of pulmonary embolism, and required thrombolytic therapy, but did not receive it due to a lack of funds. Patients in the second and third groups were immediately treated with unfractionated heparin and alteplase. Thrombolysis was not performed in the fourth group. Mortality rates were studied according to the assigned group. It was established that the risk of death increased (p<0.001) with increasing levels of D-dimer and decreased with increasing PaO2/FiO2 (p < 0.001). In the presence of a thrombus in the right heart chambers, the risk of death increased (p = 0.002), OR = 3.97 (95% CI 1.66-9.49). A trend towards reducing death risk with thrombolytic therapy was observed (p = 0.052). Data were summarised regarding the increased (p = 0.009) risk of death when thrombolytic therapy was delayed. Mortality in the fourth group was 100%. The obtained data indicate the significant effectiveness of thrombolytic therapy in the treatment of this pathology

Fibrinolysis and clinical outcomes in acute pulmonary embolism. Madras medical college pulmonary embolism (M-PER) registry from India

BackgroundAcute pulmonary embolism (APE) is the third most common cause of vascular death. Data on APE from India and other low-and middle-income countries is sparse. ObjectivesStudy the clinical characteristics, prognostic factors, in-hospital mortality (IMH) and 12 months mortality of patients with APE in India. MethodsWe prospectively enrolled 186 consecutive patients diagnosed with APE between November 2016 and November 2021 in Madras Medical College Pulmonary Embolism Registry (M-PER). All patients had electrocardiography and echocardiography. High risk patients and selected intermediate risk patients underwent fibrinolysis. Results75 % of our patients were below 50 years of age. 35 % were women. The mean time to presentation from symptom onset was 6.04 ± 10.01 days. 92 % had CT pulmonary angiography. Intermediate risk category (61.3 %) was the more common presentation followed by high risk (26.9 %). Electrocardiography showed S1Q3T3 pattern in 56 %. 76 % had right ventricular dysfunction and 12.4 % had right heart thrombi(RHT) by echocardiography. 50.5 % received fibrinolysis. Patients with RHT received fibrinolysis more frequently (78.3 % vs 46.6 %; p = 0.007). In-hospital mortality (IHM) was 15.6 %. Systemic arterial desaturation and need for mechanical ventilation independently predicted IHM. Ten patients (5.3 %) were lost to follow up. One year mortality was 26.7 % (47/176). One year mortality of patients discharged alive was similar among high, intermediate and low risk groups(14.8 % vs 1.9 % vs 10.5 %; p = 0.891). ConclusionsPatients with PE are often young and present late in India. The in-hospital and 12 months mortality were high. Low and intermediate risk groups had a high post discharge mortality similar to high risk patients.

Intracardiac Thrombus in the Right Heart: An Atypical Presentation of Behçet's Disease

Intracardiac Thrombus in the Right Heart: An Atypical Presentation of Behçet's Disease

Review of the Etiology, Diagnosis, Classification, and Therapy of Right Heart Thrombi

Right heart thrombi are a rare phenomenon associated with high mortality rates and embolization to the pulmonary bed. Diagnostic modalities include transthoracic echocardiography, contrast-enhanced echocardiography, and cardiac magnetic resonance imaging. Several treatment options for right ventricular thrombus have been described in case reports and observational studies including anticoagulation, thrombolysis, catheter-based procedures, and surgical embolectomy. Various studies have demonstrated that thrombolysis and surgical embolectomy have better survival outcomes than anticoagulation alone. Present management strategies are supported by observational studies, and further research is needed to guide therapy.

PB0456 Predictors of Thrombus Resolution in Patients on Anticoagulation for a Thrombus in the Right Heart

PB0456 Predictors of Thrombus Resolution in Patients on Anticoagulation for a Thrombus in the Right Heart

Clinical Significance of Right Heart Thrombus With and Without an Associated Pulmonary Embolism

BackgroundRight heart thrombus is a rare but serious form of venous thromboembolic disease that may be associated with pulmonary embolism. The prognosis of patients with right heart thrombus presenting without a concomitant pulmonary embolism remains ill-defined. MethodsWe conducted a multi-center observational cohort study to compare patients presenting with right heart thrombus with and without a concurrent pulmonary embolism. The primary endpoint was 90-day all-cause mortality. Multivariable regression was utilized to assess primary and secondary outcomes. ResultsOf 231 patients with right heart thrombus, 104 (45.0%) had a pulmonary embolism at admission. The median age of the cohort was 59.4 years (interquartile range 44.9-71.3). Pulmonary embolism in the setting of a right heart thrombus was associated with an increased adjusted hazard of 90-day mortality (hazard ratio 3.68; 95% confidence interval [CI], 1.51-8.97). Additionally, these patients had a higher adjusted risk of in-hospital mortality (odds ratio [OR] 2.55; 95% CI, 1.15-5.94) and admission to the intensive care unit (OR 2.45; 95% CI, 1.23-4.94). Thrombus mobility (OR 2.99; 95% CI, 1.35-6.78) and larger thrombus sizes (OR 1.04; 95% CI, 1.00-1.07) were associated with development of concurrent pulmonary embolism. ConclusionsPatients with right heart thrombus and pulmonary embolism had a more severe clinical presentation, required more advanced therapies, and had reduced survival compared with those without a concomitant pulmonary embolism. Important variables associated with development of concomitant pulmonary embolism include thrombus mobility and size. Right heart thrombus in the setting of acute pulmonary embolism represents a unique clinical entity that is associated with worse prognosis compared with right heart thrombus only.

Pinball-like free-floating right heart thrombus presenting as unexplained hypoxemia

Pinball-like free-floating right heart thrombus presenting as unexplained hypoxemia

Impact of Alteplase on Mortality in Critically Ill Patients with COVID-19 and Pulmonary Embolism.

COVID-19 is an independent risk factor for pulmonary embolism (PE). Little is known about alteplase therapy in this patient group. A retrospective study analyzed 74 patients with PE and acute respiratory distress syndrome (ARDS) due to COVID-19 who were hospitalized in the intensive care unit in 2021. Patients with or without confirmed right heart thrombi (RHT) were treated with unfractionated heparin or alteplase. The mortality rate in patients with RHT treated with heparin was 100% compared to 37.9% and 55.2% in those treated with alteplase without RHT and alteplase with RHT, respectively. The risk of death in the alteplase group increased with delayed thrombolysis (p = 0.009, odds ratio (OR) = 1.73 95% CI (confidence interval) 1.14-2.62), increased D-dimer concentration (p = 0.02, OR = 1.43 95% CI 1.06-1.93), and decreased PaO2/FiO2 ratio (p = 0.001, OR = 0.56 95% CI 0.41-0.78). The receiver operating characteristic method determined that a 1-day delay in thrombolytic treatment, D-dimer concentration >5.844 mg/L, and PaO2/FiO2 <144 mmHg predicted a fatal outcome. The risk of death in patients with severe COVID-19 with ARDS and PE increases with higher D-dimer levels, decreased PaO2/FiO2, and delayed thrombolytic treatment. Thrombolysis seems to be treatment of choice in severe COVID-19 with PE and RHT. It should be carried out as soon as possible after the diagnosis is established.

Right heart thrombus in transit and peripherally inserted central catheters

Right heart thrombus in transit or “free-floating right heart thrombus” is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored.

The completeness of the left atrial appendage amputation during routine cardiac surgery

BackgroundLeft atrial appendage (LAA) is the origin of most heart thrombi which can lead to stroke or other cerebrovascular event in patients with non-valvular atrial fibrillation (AF). This study aimed to prove safety and low complication rate of surgical LAA amputation using cut and sew technique with control of its effectiveness.Methods303 patients who have undergone selective LAA amputation were enrolled in the study in a period from 10/17 to 08/20. The LAA amputation was performed concomitant to routine cardiac surgery on cardiopulmonary bypass with cardiac arrest with or without previous history of AF. The operative and clinical data were evaluated. Extent of LAA amputation was examined intraoperatively by transoesophageal echocardiography (TEE). Six months in follow up, the patients were controlled regarding clinical status and episodes of strokes.ResultsAverage age of study population was 69.9 ± 19.2 and 81.9% of patients were male. In only three patients was residual stump after LAA amputation larger than 1 cm with average stump size 0.28 ± 0.34 cm. 3 patients (1%) developed postoperative bleeding. Postoperatively 77 (25.4%) patients developed postoperative AF (POAF), of which 29 (9.6%) still had AF at discharge. On 6 months follow up only 5 patients had NYHA class III and 1 NYHA class IV. Seven patients reported with leg oedema and no patient experienced any cerebrovascular event in early postoperative follow up.ConclusionLAA amputation can be performed safely and completely leaving minimal to no LAA residual stump.

Clinical characteristics and treatment of patients with central pulmonary embolism and right heart thrombus.

Right heart thrombus (RHT), also known as clot in transit, is an uncommon finding in pulmonary embolism (PE) that is associated with increased inpatient mortality. To date, there is no consensus on the management of RHT. Therefore, we aim to describe the clinical features, treatments, and outcomes of patients with simultaneous RHT and PE. This is a retrospective, cross-sectional, and single-center study of hospitalized patients with central PE who had RHT visualized on transthoracic echocardiography (TTE) from January 2012 to May 2022. We use descriptive statistics to describe their clinical features, treatments, and outcomes, including mechanical ventilation, major bleeding, inpatient mortality, length of hospital stay, and recurrent PE on follow-up. Of 433 patients with central PE who underwent TTE, nine patients (2%) had RHT. The median age was 63 years (range 29-87), most were African American (6/9), and females (5/9). All patients had evidence of RV dysfunction and received therapeutic anticoagulation. Eight patients received RHT-directed interventions, including systemic thrombolysis (2/9), catheter-directed suction embolectomy (4/9), and surgical embolectomy (2/9). Regarding outcomes, 4/9 patients were hemodynamically unstable, 8/9 were hypoxemic, and 2/9 were mechanically ventilated. The median length of hospital stay was six days (range 1-16). One patient died during hospital admission, and two patients had recurrent PE. We described the different therapeutic approaches and outcomes of patients with RHT treated in our institution. Our study adds valuable information to the literature, as there is no consensus on the treatment of RHT. Right heart thrombus (RHT) was a rare finding in central pulmonary embolism. Most patients with RHT had evidence of RV dysfunction and pulmonary hypertension. Most patients received RHT-directed therapies in addition to therapeutic anticoagulation.

A modern view on the diagnostic role of endothelial dysfunction biomarkers and the possibilities of its correction

Highlights. The article presents a review of literature data on the diagnostic role of endothelial dysfunction biomarkers. The review provides an overview of the main indicators, their significance in various pathologies, and presents possible therapeutic strategies for preventing endothelial dysfunction.Abstract. Endothelial dysfunction is a characteristic feature of each stage of the cardiovascular continuum – a series of events from hypertension to the development of atherosclerosis and coronary heart disease, thrombus formation, myocardial infarction, and heart failure. Due to the prominent role of endothelial dysfunction in the pathogenesis of many vascular diseases, it is a significant therapeutic target. It is important to note that circulating markers of endothelial activation and damage characterize the severity of the disease and can be used to evaluate the efficacy of treatment and subsequent prognosis. The purpose of this review is to provide up–to-date data on endothelial function, discussing its clinical relevance in the cardiovascular continuum, the latest insights in molecular and cellular biology, and their implications for clinical practice, with a focus on new methods of therapeutic approaches for correcting endothelial dysfunction.

Low dose ultra-slow infusion thrombolytic therapy (LDUSITT) as an alternative option in a COVID-19 patient with free-floating right atrial thrombus: a case report and review of literature

The hyper-coagulopathy nature of COVID-19 is a prevalent consequence among patients. Free-floating right atrial thrombi are a relatively rare finding and the optimal therapy is a therapeutic dilemma.We present a 37-year-old woman with acute dyspnea and fatigue. Several ground glass opacities were shown on computed tomography of chest that further proved to be associated with severe COVID-19 disease. A transthoracic echocardiography revealed a mobile right atrial mass with bilateral pulmonary embolism. She was considered high risk for surgical therapy by cardiovascular surgeons. She was then started on anticoagulation therapy for 5 days however the size regression of the thrombus remained unchanged. A regimen of low dose (24 mg) ultra-slow (24 h) intravenous infusion of alteplase, without bolus was initiated. Following the third day of thrombolytic therapy, the control echocardiography demonstrated complete resolution of the thrombus.Prolonged infusion of low dose fibrinolytics can be an alternative treatment to surgery for right heart thrombi.

Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients.

The presence of right heart thrombi in transit (RHTiT) in the setting of acute pulmonary embolism (PE) is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high- or intermediate-high-risk PE with coexisting RHTiT. A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute PE with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography and laboratory tests. Eligibility criteria for surgical treatment were acute PE with RHTiT, right ventricular overload on imaging studies and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end point was hospital all-cause mortality; secondary end points were perioperative complications and long-term mortality. The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13-98). There was 1 death in the long-term follow-up, not related to PE. Surgical treatment of patients with acute PE and coexisting RHTiT can provide favourable results.

Free-floating right heart thrombus with pulmonary embolism - a case report

Introduction. Right heart thrombus is uncommon and it is usually detected by echocardiography in patients with venous thromboembolism. Thrombi attached to the atrial or ventricular wall have a good prognosis; however, free-floating ?snake-like? thrombi are usually associated with massive, unstable pulmonary embolism and high mortality. Case Report. A 43-year-old male patient visited a cardiologist complaining about rapid fatigue and shortness of breath with minimal effort in the last week. An echocardiographic examination confirmed a right heart thrombus and a pulmonary embolism. After the examination, the case was presented to the Heart Team, which made a decision to perform a surgery. After the usual preoperative preparation for emergency surgery, the patient underwent surgery under general endotracheal anesthesia via median sternotomy. Conclusion. The right heart thrombus is associated with risks of possible embolization to the pulmonary circulation and potential circulatory collapse. There was a considerable discrepancy between the apparently mild clinical presentation and the alarming echocardiographic finding of a huge free-floating thrombus. Despite the lack of standardized and precise recommendations for the optimal therapeutic strategy, surgical approach seems to be the best option in emergency cases with large free-floating thrombi.

Right heart thrombus in a patient with acute pulmonary embolism - a practice in hide-and-seek with guidelines

Introduction. Right heart thrombus (RHT) is a relatively rare phenomenon found in 4% of patients with acute pulmonary embolism (PE), and some reports show that the presence of RHT is associated with poor outcomes. The optimal treatment of patients with PE and RHT is still controversial, with no clear consensus. Case report. A 38-year-old woman with repeated chest pain and worsening dyspnea was admitted to the hospital. The echocardiographical exam showed a large thrombus floating in the right atrium, protruding through the tricuspid valve into the right ventricle. Massive bilateral pulmonary embolism was confirmed by computed tomography pulmonary angiogram. Bearing these findings in mind and due to the clinical and hemodynamic instability of the patient, thrombolytic therapy was immediately initiated (alteplase), which resulted in excellent clinical outcomes with no adverse events at follow-up. Conclusion. Treating patients with PE and RHT is very difficult. While waiting for the results of some future randomized clinical trials on this topic, the treatment of these patients should be based on current guidelines while also considering the patient?s hemodynamic stability.

Anticoagulation therapy for pulmonary embolism involving a myxoma mimicking, giant type C thrombus: A case report.

Right heart thrombus (RHTh) with concurrent acute pulmonary embolism (PE) is rare and can seriously destabilize hemodynamics, leading to an emergency situation with high mortality. Diagnosis and treatment of RHTh with acute PE are not yet standardized. There are few reports of acute PE concurrent with RHTh and even less is known about patients with a right heart mural thrombus. For physicians, the diagnostic choice and treatment of these patients are particularly difficult due to the lack of knowledge. Here, we report a rare case of partial mural RHTh (type C RHTh) with acute PE. The mural mass in the right heart was initially diagnosed as atrial myxoma according to transthoracic echocardiography (TTE), and both pulmonary embolus and the mural mass were completely absorbed after administering Rivaroxiban. This case suggests that TTE alone is insufficient to identify and diagnoses a right heart mural mass such as this. However, novel oral anticoagulants may be effective at alleviating PE with type C RHTh.

THROMBUS-IN-TRANSIT: A NARRATIVE IN SERIAL ULTRASOUND

THROMBUS-IN-TRANSIT: A NARRATIVE IN SERIAL ULTRASOUND

CLOT IN TRANSIT: THE ROLE OF POINT-OF-CARE ULTRASOUND IN EARLY DIAGNOSIS AND IMPROVED OUTCOMES

CLOT IN TRANSIT: THE ROLE OF POINT-OF-CARE ULTRASOUND IN EARLY DIAGNOSIS AND IMPROVED OUTCOMES