High Embolic Risk Research Articles

Thromboembolic diseases from a cardiological point of view

Thromboembolic disease is associated with a high mortality. It can be divided into two groups: embolism from a venous and embolism from an arterial side. This article gives an overview on thromboembolic disease (with a focus on pulmonary embolism and ischemic stroke) from a cardiologist's perspective.The therapeutic options for acute pulmonary embolism range from anticoagulation to fibrinolysis to interventional recanalization and surgery. The deciding factor for choice of therapy is the risk of early death. Besides clinical parameters, laboratory markers like cardiac troponin and right ventricular function on echocardiography or CTPA (computed tomography pulmonary angiography) are used to determine the early mortality risk. In hemodynamically instable patients, immediate thrombolysis is required, whereas patients with intermediate and low risk can be treated with anticoagulation. Interventional recanalization is currently being studied in patients at risk for development of CTEPH (chronic thromboembolic pulmonary hypertension) or an intermediate risk of early mortality.In ischemic stroke, early interdisciplinary workup involving a cardiologist is paramount. Post stroke screening should include monitoring for arrythmias (especially atrial fibrillation) and transthoracic echocardiography as well as sonography of extra- and intracranial arteries. If no embolic source can be detected (embolic stroke of undetermined source), transesophageal echo can be helpful to detect intracardiac shunts like patent foramen ovale (PFO) or intracardiac tumors. Post stroke care includes secondary prevention measures like risk factor modification and lipid lowering therapy as well as anticoagulation. In high risk for paradoxical embolization, interventional PFO closure can be performed. Interventional closure of the left atrial appendage (LAA) can be discussed in patients with both high thromboembolic and bleeding risk.

MR Imaging of Carotid Artery Atherosclerosis: Updated Evidence on High-Risk Plaque Features and Emerging Trends.

MR imaging is well-established as the criterion standard for carotid artery atherosclerosis imaging. The capability of MR imaging to differentiate numerous plaque components has been demonstrated, including those features that are associated with a high risk of sudden changes, thrombosis, or embolization. The field of carotid plaque MR imaging is constantly evolving, with continued insight into the imaging appearance and implications of various vulnerable plaque characteristics. This article will review the most up-to-date knowledge of these high-risk plaque features on MR imaging and will delve into 2 major emerging topics: the role of vulnerable plaques in cryptogenic strokes and the potential use of MR imaging to modify carotid endarterectomy treatment guidelines.

Intracardiac echocardiography-guided left atrial appendage occlusion: The path to independence

Introduction and ObjectivesTransesophageal echocardiography (TEE) has been the standard method for guiding left atrial appendage occlusion (LAAO) procedures. Recently, intracardiac echocardiography (ICE) has emerged as an alternative to TEE due to several advantages, particularly the avoidance of general anesthesia. This analysis aims to assess the safety, feasibility and efficacy of ICE-guided LAAO procedures. MethodsWe performed a retrospective analysis of ICE-guided LAAO procedures, including a comparison of embolic and bleeding events with the predicted standard scores and a comparison with TEE-guided procedures. ResultsA total of 88 patients underwent echocardiography-guided percutaneous LAAO (43 patients with TEE and 45 with ICE), mean age 74.9 years, 68.2% male. In the ICE-guided population, the technical success rate was 93% and the major complication rate was 8.8%. During follow-up, yearly stroke and major bleeding rates were 1.4% and 8.4%, respectively, compared to the 4.0% and 8.7% predicted by the CHA2DS2-VASc and HAS-BLED scores. In the TEE versus ICE analysis (similar baseline characteristics), no statistically significant differences were seen regarding technical success (95.3% vs. 93.3%), procedure-related complications (14.0% vs. 8.9%), device thrombus (2.3% vs. 0%), residual minor peridevice leaks (14.0% vs. 24.4%), one-year all-cause mortality (9.3% vs. 4.4%), stroke (9.3% vs. 2.2%) or major bleeding events (9.3% vs. 11.1%). ConclusionICE-guided LAAO was a safe and effective therapeutic strategy in a high embolic and bleeding risk population, compared to the event rates predicted by the CHA2DS2-VASc and HAS-BLED scores. The ICE-guided procedure compared well to TEE-guided procedures regarding procedure feasibility, safety, and efficacy.

Acute Myocardial Infarction, Pulmonary Embolism, and a Suspicious Aortic Mass: A Case of Complex Differential Diagnosis and Management

Abstract Introduction Ascending aorta floating thrombus is a rare entity. Without rapid and specific management this condition has potential catastrophic consequences. Case presentation We report the case of a young woman diagnosed with acute ST elevation myocardial infarction (STEMI) and pulmonary embolism (PE) which revealed the existence of a suspicious aortic mass with a high embolic risk. The definite treatment was surgical resection, and the etiology of the mass was confirmed by histopathological examination. In this case, protein C deficiency was the only significant factor predisposing to thrombus formation. Conclusions This case illustrates the importance of performing a rapid and comprehensive cardiovascular evaluation, even when the initial presentation seems to suggest a clear diagnosis. Ascending aortic floating thrombus requires individualized management, and in specific situations a surgical approach is recommended.

P130 FINGER ISCHEMIA IN A YOUNG LADY: EXPECT THE UNEXPECTED FROM A PAPILLARY FIBRO–ELASTOMA

Abstract Case presentation: In December 2022, A 32–y old women presented to the emergency department of our institution for pain and acrocyanosis of the 3rd and 4th finger of the right hand, compared abruptly 10 hours before. Physical examination was otherwise normal, she was apyretic. Her previous medical history was unremarkable, she did not take any medication and was a light smoker. Blood samples including blood count, platelets, coagulation tests, liver and kidney function, and inflammatory markers were normal. An echocardiogram was prescribed to rule out significant cardiovascular disease. The exam showed: normal left and right ventricular dimensions and systolic function, and absence of significant valvular disease. A highly mobile, iso–echoic mass was noted inside the left ventricle, with a major diameter of 8 mm; it was attached to the antero–lateral papillary muscle, not involving the mitral valve leaflets, and it had a frond–like appearance. Findings were consistent with a fibroelastoma (PFE; figure 1, 2). Doppler examination excluded pathology of ascending aorta, right subclavian artery, and demonstrated patency of arteries of the right arm and right hand. The case was compatible with peripheral embolization from the cardiac mass. A cardiac CT scan confirmed the echo findings and ruled out significant coronary disease. The patient underwent cardiac surgery two days later. With median sternotomy and cardiopulmonary bypass, the left ventricle was reached through aortotomy. A multilobular yellowish mass was seen attached to the antero–lateral papillary muscle, and was completely resected (figure 3); chordae tendineae were preserved. Macroscopic examination (figure 3) and histological findings confirmed the diagnosis of PFE. Post operative course was unremarkable. Discussion PFEs are benign tumors most commonly involving aortic valve, followed by mitral valve; atypical origins including mitral subvalvular apparatus, as in our case, has seldom been described. Most cases of PFE are asymptomatic, limited in dimensions and discovered incidentally. Interestingly, Raynaud phenomenon was at first suspected as cause of acrocyanosis in our patient, but it was inconsistent with biochemical findings, so that an echocardiogram was prescribed. Echo and CT aspects of the mass were typical for PFE, and it appeared at high embolic risk being pedunculated and highly mobile. Given the peripheral ischemic event occurred, prompt surgical resection was performed successfully.

P295 WHEN TAVI IS THE RIGHT CHOICE

Abstract Clinical case We describe a case of a 62–y–old man, affected by hypertension, insulin–dependent diabetes mellitus, advanced liver cirrhosis. After screeing, the patient was listed for liver transplantation. On September 2022, the patient was admitted to our Emergency Room due to HF in class NYHA III. The transthoracic echocardiogram showed a severe aortic regurgitation with mobile vegetations, the largest of which is more than 10 mm on the right aortic cusp. Normal biventricular function was observed with sPAP of 45 mmHg. Thus, we concluded for post–endocarditis severe aortic regurgitation. We discussed tha case in our Department Heart Team with the concomitant presence of the Liver Team. We considered the patient at high surgical risk, mostly due to the risk of postoperative hepatic insufficiency. So, we decided for a TAVI off–label. So, we impantanted a Sapien 3 Ultra 26 mm through transfemoral access. To reduce the risk of cerebral embolization, we used Triguard 3 system, while to prevent coronary embolization we used a closed stent into the right coronary ostia, ready to be opened. The patient was discharged in the fourth postoperative day, without conduction disturbances. The postoperative echo showed normal valvular function and absence of paravalvular leakages. Conclusions Patients with advanced liver cirrhosis are at risk of organ failure following use of extracorporeal circulation. In selected patients, TAVI may be a valid alternative. The peculiarity of the specific case was due to the use of the TAVI in an off–label procedure of aortic insufficiency with the simultaneous presence of mobile vegetation at high embolic risk.

Giant Left Atrial Appendage Aneurysm or Pericardial Effusion: A Misleading Appearance on Echocardiography and a High Risk of Rupture

Left atrial appendage (LAA) aneurysm or giant LAA is an uncommon condition. It could be discovered incidentally during echocardiography examination or in symptomatic patients presenting with tachycardia or embolic events. The giant LAA is a serious condition with a high embolic risk that can cause respiratory distress and even cardiac arrest in children. A conservative surgical approach based on resection of the LAA is recommended and is mostly safe. We report the case of a four-year-old girl presenting with a symptomatic giant LAA removed successfully. The echo-cardiographer must be aware of its appearance mimicking a pericardial effusion and focus on its possible association with other congenital lesions. There are several therapeutic strategies, all with proven efficacy and safety.

PO-02-081 PERCUTANEOUS REMOVAL OF LARGE VEGETATION FACILITATES SAFE TRANSCUTANEOUS LEAD EXTRACTION: A SINGLE CENTER EXPERIENCE

Infective endocarditis (IE) is the most common indication for transvenous lead extraction (TLE), and it is associated with significant morbidity and mortality. Complete removal of the device in addition to antibiotics is required, however large vegetations (>2-3cm) on either the lead or the tricuspid valve confer a high risk of vegetation embolization with standard lead extraction. Vegetation size larger than 2cm appear to have higher incidence of intraprocedural clinically significant pulmonary embolism. An open surgical approach is usually recommended in this situation to mitigate the risk of embolization, however, surgical extraction is associated with increased morbidity/mortality and in some patients the risk is prohibitive. Percutaneous approach to remove large vegetations from tricuspid valve has been reported to be safe in several recent case reports The purpose of our study is to describe our single-center experience of the management of patients with a large vegetation involving the leads and/or the tricuspid valve. The use of percutaneous tricuspid valve/lead vegetation removal permitted or facilitated successful TLE avoiding cardiothoracic surgery We reviewed the perioperative course of 5 consecutive patients with large tricuspid valve and/or lead vegetation referred for device/lead extraction due to endocarditis. Patients with large vegetations considered at increased risk of embolization with transcutaneous extraction were referred for percutaneous vegectomy prior to TLE. Vegectomy procedure is done at our institution using the percutaneous catheter-based system FlowTriever aspiration catheter with FLEX technology (Inari Medical, Irvine, CA USA) with the guidance of intracardiac echocardiogram through femoral vein access (Figure 1). Over a 15-month period, 5 patients presented with large vegetations that precluded TLE due to embolization risk. Four patients (80%) were male, with an average age of 60 years, and the average vegetation size was 2.7 cm (2.4-3.2 cm). All patients underwent vegectomy followed by lead extraction as a staged procedure without complication. All patients survived the index hospitalization (see Table 1 for details) Percutaneous removal of large tricuspid valve/lead vegetations prior to lead extraction is a safe and effective way to manage patient with endocarditis and large vegetations thereby avoiding the morbidity and mortality associated with open heart surgeryTabled 1Table 1Patient #Age (years)Device Type# of LeadsOrganismVegetation Size (cm)Vegetation LocationComplications166CRT-D3MSSA2.5RV LeadNone263DC PPM2No growth2.4RA/RV LeadNone368CRT-D (HIS Lead)3Streptococcus2.5RA LeadNone456ICD (Dual Coil)1Corynebacterium3.0RV Lead/TVNone548DC PPM2MRSA3.2RA LeadNoneCRT-D: Cardiac resynchronization therapy – defibrillator; MSSA: Methicillin sensitive staph aureus; RV: right ventricular; DC PPM: Dual chamber permanent pacemaker; RA: right atrial; ICD: implantable cardioverter defibrillator; MRSA: Methicillin resistant staph aureus; TV: Tricuspid valve Open table in a new tab

Clinical benefits and risks of anticoagulation therapy according to the degree of chronic kidney disease in patients with atrial fibrillation

BackgroundThe clinical benefits and risks of anticoagulation therapy in patients with chronic kidney disease (CKD) are still inconclusive. We describe the outcomes of patients with atrial fibrillation (AF) after anticoagulation therapy according to differences in creatinine clearance (CrCl). We also aimed to determine the patients who could benefit from anticoagulation therapy.MethodsThis is a retrospective observational review of patients with AF who were managed at Asan Medical Center (Seoul, Korea) between January 1, 2006, and December 31, 2018. Patients were categorized into groups according to their baseline CrCl by Cockcroft–Gault equation and their outcomes were evaluated (CKD 1, ≥ 90 mL/min; CKD2, 60–89 mL/min; CKD3, 30–59 mL/min; CKD4, 15–29 mL/min; CKD 5, < 15 mL/min). The primary outcome was NACE (net adverse clinical events), defined as a composite of all-cause mortality, thromboembolic events, and major bleeding.ResultsWe identified 12,714 consecutive patients with AF (mean 64.6 ± 11.9 years, 65.3% male, mean CHA2DS2-VASc score 2.4 ± 1.6 points) between 2006 and 2017. In patients receiving anticoagulation therapy (n = 4447, 35.0%), warfarin (N = 3768, 84.7%) was used more frequently than NOACs (N = 673, 15.3%). There was a higher 3-year rate of NACE with renal function deterioration (14.8%, 18.6%, 30.3%, 44.0%, and 48.8% for CKD stages 1–5, respectively).The clinical benefit of anticoagulation therapy was most prominent in patients with CKD 1 (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.37–0.67), 2 (HR 0.64 CI 0.54–0.76), and 3 (HR 0.64 CI 0.54–0.76), but not in CKD 4 (HR 0.86, CI 0.57–1.28) and 5 (HR 0.81, CI 0.47–1.40). Among patients with CKD, the benefit of anticoagulation therapy was only evident in those with a high risk of embolism (CHA2DS2-VASc score ≥ 4, HR 0.25, CI 0.08–0.80).ConclusionAdvanced CKD is associated with a higher risk of NACE. The clinical benefit of anticoagulation therapy was reduced with the increasing CKD stage.

Cardiac Calcified Amorphous Tumor: An Unusual Etiology for Recurrent Cardioembolic Strokes (P3-5.026)

<h3>Objective:</h3> To report a patient with recurrent cardioembolic strokes, in whom an underlying calcified amorphous tumor (CAT) of the heart was detected as the etiology, 2 years after initial presentation. <h3>Background:</h3> CAT of the heart is a rare intracavitary cardiac mass characterized histologically by amorphous fibrinous material and calcification. It has a tendency for embolism. We use this illustrative case to bring awareness for this rare entity and utility of advanced cardiac imaging. <h3>Design/Methods:</h3> An 87-year-old woman with recurrent recent strokes was evaluated for her 5^th stroke. Her neuroimaging had suggested an embolic etiology, but routine cardiac workup had not identified a source. After her 5^th stroke happened despite being on anticoagulation, a trans-esophageal ECHO (TEE) was done followed by cardiac MRI. <h3>Results:</h3> TEE and MRI showed a left atrial non-enhancing calcified mass attached by a stalk to the interatrial septum suspicious for CAT. The tumor was surgically resected. Histological examination showed nodular amorphous calcification against the background of degenerating fibrinous material consistent with CAT. The immediate post-operative period was uneventful, and the patient was discharged to a rehabilitation facility on aspirin monotherapy. <h3>Conclusions:</h3> CAT is a rare cardiac tumor, and its presence is suggested by the presence of calcification of an intracardiac mass on cardiac imaging. The presence of mitral annular calcification (MAC) and renal disease can be additional clues to CAT being the cause for an intracardiac mass, which can then be identified by advanced cardiac imaging. A definitive diagnosis can be made only on pathology, and the definitive treatment is surgical. MAC-related CAT can grow rapidly, has a high embolic risk, and should be removed expeditiously to prevent embolic strokes, even in asymptomatic individuals. <b>Disclosure:</b> Mr. Sharma has nothing to disclose. Dr. Annam has nothing to disclose. Bilal Ali has nothing to disclose. Dr. Guler has nothing to disclose. Dr. Hussein has nothing to disclose.

Clinical Outcome After Left Ventricular Thrombus Resolution: Who Needs Long-Term or Lifetime Use of Anticoagulants?

Background Patients with left ventricular thrombus (LVT) resolution can have LVT recurrence and risk for thromboembolism. However, these outcomes after LVT resolution are not well known. We aimed to assess the prevalence, risk factors, and clinical outcomes for LVT recurrence in patients with LVT resolution to inform follow-up and treatment. Methods and Results Patients with LVT resolution were identified retrospectively from a large echocardiography database between January 2009 and May 2022. Participants had echocardiograms at 3 time points, including baseline at LVT diagnosis, at LVT resolution, and a follow-up for identification of LVT recurrence. The cumulative LVT recurrence rate was estimated by the Kaplan-Meier method, and predictors of LVT recurrence were evaluated using Cox regression analysis. Among 115 patients with LVT resolution, 28 (24.3%) had LVT recurrence at a median follow-up of 1.2 (0.5-2.8) years. LV aneurysm (hazard ratio [HR], 2.59 [95% CI, 1.20-5.58], P=0.015) and anticoagulant use (HR, 0.12 [95% CI, 0.04-0.41], P=0.001) were predictors of LVT recurrence on multivariable analysis. Patients with an LV aneurysm who did not receive any anticoagulation demonstrated an LVT recurrence rate of 69.5%, whereas those without an LV aneurysm who received anticoagulation had a recurrence rate of 0%. Patients with LVT recurrence had a higher incidence of an embolic event (10.7% versus 1.1%, P=0.016). Conclusions LVT recurrence after LVT resolution is common, especially in those with an LV aneurysm, and is associated with a higher embolic risk. Continued anticoagulation is protective against LVT recurrence, although bleeding risk needs to be considered. These findings can inform follow-up and treatment of patients with documented LVT resolution.

Impact of Anesthesia on D-Dimer Concentration in Patients under Going Surgery Associated with High Risk for Pulmonary Embolism

Background: Pulmonary embolism (PE) is a blood clot that blocks and stops blood flow to an artery in the lung. It (PE) is a common and often fatal complication of venous thromboembolic disease (VTE). Pulmonary embolism (PE) is the third leading cause of cardiovascular-related death and is responsible for the hospitalization of a huge number of patients yearly. D-dimer concentration is a diagnostic marker of pulmonary embolism (PE). Aim of the study: This study aimed to assess the impact of anesthesia on D-dimer concentration in patients undergoing surgery associated with high risk for pulmonary embolism. Methods: This prospective observational study was conducted in the Department of Anesthesia &amp; ICU, Mugda Medical College Hospital, Dhaka, Bangladesh during the period from January 2022 to December 2022. In total 57 patients undergoing surgery associated with a high risk for pulmonary embolism were enrolled in this study as study subjects. In this study, we examined the changes imparted by anaesthesia surgery on the end-tidal CO2/O2 compared with the D-dimer. Blood samples were immediately analyzed for fibrinogen and D-dimer concentrations. Breath samples were obtained from 1 min of spontaneous tidal breaths delivered via mouthpiece while the patientst breathed room air. Results: In this study, the mean transoperative value changes of respiratory rate (breaths/min), pulse rate (beats/min), systolic blood pressure (mmHg), SaO2 (%, room air) and minute ventilation (ml/min) were found as 0.23, 11.2, 15.33, 2.05 and 779.42 respectively. The pre-operative mean D-dimer 1042.57 ±202.47 ng/ml had been significantly increased to 1277.58 ±211.28 ng ml postoperatively, where the p-value was found as &lt;0.001. On the other hand, the pre-operative mean End-tidal CO2 ⁄ O2, 0.3 ±0.02 had been decreased to 0.3 ±0.01 (Not significant). But the mean fibrinogen (mg/dl) had increased significantly (p&lt;0.001). Conclusion: As per the findings of this study we can conclude that the stress ...

Incidental Discovery of a Cardiac Thrombus Mimicking a Right Atrial Myxoma in a Young Female Patient – A Case Report

Abstract Introduction Cardiac masses are at the attention of health specialists since the development of echocardiography. Even though imaging is an excellent tool for diagnosis, the clinical presentation, risk factors, and hemodynamic status of the patients are important in establishing the diagnosis and subsequent management. The purpose of this presentation is to assess the difficulty of diagnosis in the case of an intracardiac mass and its therapeutic management. Case report A 29-year-old female with paresthesia in the left arm and a systolic tricuspid murmur underwent echocardiography, which revealed a mass of 35/20 mm in the right atrium. Due to the high embolic risk, the patient was referred to the cardiac surgery department and underwent surgical removal of the cardiac mass, which presented the macroscopical aspect of a myxoma. However, the histopathological examination revealed a right atrial thrombus. Conclusion Right heart thrombi represent a challenging diagnosis that involves a multidisciplinary team for the diagnosis and treatment of the patient.

Lung cancer embolization causing acute limb ischemia: a case report

BackgroundAcute tumour embolism to the popliteal artery resulting in limb-threatening ischemia is a rare complication of neoplastic disease. Generally, tumors embolize to the pulmonary circulation via the venous system. In this case, the originating tumor was a lung cancer of a large size and advanced stage that had invaded the left atrium of the heart and disseminated in the systemic circulation. The tumor likely fragmented, resulting in showering to the right popliteal artery, superior mesenteric artery, and left renal artery, which is a unique presentation of tumor embolism.Case reportWe present a case of a 62-year-old Caucasian gentleman with a large left lower lobe squamous cell lung cancer that had invaded into the left atrium via the pulmonary veins. He presented with acute limb threatening ischemia. A computed tomographic angiogram revealed an occlusion of the left popliteal artery as well as embolization to the superior mesenteric artery and the right renal artery. He was started on intravenous heparin and underwent an emergency popliteal embolectomy and calf fasciotomies, which was limb saving. His fasciotomy wounds were closed after 1 week and he was discharged on anticoagulation.ConclusionThis is a rare case of tumor embolism resulting in both an embolectomy and calf fasciotomies. In the light of such cases, we suggest that tumors invading the bloodstream should be considered high risk for embolization and hypothesize that prophylactic antithrombotic therapy may avoid major morbidity.

Temporal Trend of the Incidence and Characteristics of Renal Infarction: Korean Nationwide Population Study.

Large-scale studies about epidemiologic characteristics of renal infarction (RI) are few. In this study, we aimed to analyze the incidence and prevalence of RI with comorbidities in the South Korean population. We investigated the medical history of the entire South Korean adult population between 2013 and 2019 using the National Health Insurance Service database (n = 51,849,591 in 2019). Diagnosis of RI comorbidities were confirmed with International Classification of Disease, Tenth Revision, Clinical Modification codes. Epidemiologic characteristics, distribution of comorbidities according to etiologic mechanisms, and trend of antithrombotic agents were estimated. During the 7-years, 10,496 patients were newly diagnosed with RI. The incidence rate increased from 2.68 to 3.06 per 100,000 person-years during the study period. The incidence rate of RI increased with age peaking in the 70s with 1.41 times male predominance. The most common comorbidity was hypertension, followed by dyslipidemia and diabetes mellitus. Regarding etiologic risk factor distribution, high embolic risk group, renovascular disease group, and hypercoagulable state group accounted for 16.6%, 29.1%, and 13.7% on average, respectively. For the antithrombotic treatment of RI, the prescription of antiplatelet agent gradually decreased from 17.0% to 13.0% while that of anticoagulation agent was maintained around 35%. The proportion of non-vitamin K antagonist oral anticoagulants remarkably increased from only 1.4% to 17.6%. Considering the progressively increasing incidence of RI and high prevalence of coexisting risk factors, constant efforts to raise awareness of the disease are necessary. The current epidemiologic investigation of RI would be the stepping-stone to establishing future studies about clinical outcomes and optimal treatment strategies.

Characteristics and outcomes of angiovac-assisted debulking of intracardiac masses, thrombi, and endocarditis.

Traditional management for right-sided infective endocarditis and other adherent masses centers around balancing the risks and benefits of open surgical removal against medical therapy. Single-center study analysis of 19 patients who underwent vacuum-assisted debulking and/or en bloc removal of right-sided infective endocarditis and other adherent masses between September 2017 and November 2021. Clinical outcomes during the perioperative period, postoperative period, hospital course, and post-discharge were analyzed. We included 12 male and 7 female patients with an average age 47.4 ± 16.8. Relevant risk factors included 47.4% of patients with active intravenous drug use (IVDU), 21.1% of patients with a history of permanentpacemaker (PPM) or implantable cardioverter-defibrillator (ICD), and 5.3% of prior malignancy with mediastinal radiation. 31.6% of patients had documented right-sided masses from a non-infectious etiology, while 68.4% of patients were noted to have right-sided infective endocarditis (RSIE). All patients were found to have large, mobile masses or vegetations at high risk for embolization to the pulmonary vasculature. Average in-hospital length of stay was 17.8 ± 12.2days, blood cultures cleared postoperatively in 8.9 ± 7.3days, periprocedural mortality was 0%, subsequent open surgical valvular repair during the same admission was 5.3%, and in-hospital mortality was 5.3%. Within 6weeks of follow-up, 15.8% of patients were readmitted for recurrence of bacteremia, 10.5% of patients were found to have new pulmonary embolism, and 15.8% of patients underwent open surgical valvular repair. Total death after 1-year and 2-years was 15.8% and 5.3%, respectively. Recurrence of bacteremia was 21.1% within 1-year. AngioVac is a viable therapeutic strategy for select patients with intravascular and intracardiac right-sided masses including thrombi, emboli, or infective masses such as endocarditis.

How to Anticoagulate Patients with Heart Failure and Cancer?

Patients with cancer have a high risk of deep vein thrombosis and pulmonary embolism, as well as a risk of developing atrial fibrillation (AF) secondary to antineoplastic treatment. These events have a poor prognosis and depend on factors related to the tumor and the ongoing therapy. They are usually elevated during the first 6 months of treatment. […] How to Anticoagulate Patients with Heart Failure and Cancer?

299 LEFT VENTRICULAR APICAL THROMBUS

Abstract LV thrombus is a complication of AMI. It is estimated that 40-60% of patients with large anterior wall MI will develop a LV thrombus. The risk is highest during the first 3 months following AMI. Accurate and timely detection is important as it poses a high risk for thromboembolic events. Advances in technology have improved the detection rate of intracardiac thrombi, but several uncertainties still remain regarding the optimal treatment strategy within daily clinical practice. We report a case of large LV thrombus in a 61-year-old male with extensive anterior wall MI. A 61-year-old man, hypertension, former smoker, subjected to epatic orthotopic transplant for HCC and treated with immunosuppressive therapy (Everolimus), following development of lymphocytic leukemia in fu. He underwent thoracic ct, wich showed a hypodense imaging in the left ventricular apex referable to thrombotic formation large 2cm, with endocardial rim hypointense like ischemic outcomes. The ECG demonstrated Q waves in anterior leads and biphasic T waves in the same leads. The patient was absolutely asyntomatic. A transthoracic echocardiography, showed the apical mass (2×0,9cm) very mobile and akinesia and thinning of the left ventricol middle-apical wall with apical aneurysmatic evolution. A CMR, confirmed the presence of the thrombus and showed defects at the subendocardial layer of the anterior wall and interventricular septal with also involvement of all the apex; the burden of late gadolinium enhancement (ischemic pattern) extended to the same segment. Coronary angiography showed subocclusion involving the second tract of the left anterior descending (99%) and critical coronary stenosis of the third tract of the right coronary (70%). The thrombus was completely removed surgically through left atriotomy, in prevention of embolization due to the thrombus dimension, the motility and the labile docking station. The histological examination confirmed the thrombotic nature of the mass. International guidelines agree on recommending anticoagulation therapy for patients affected by left ventricular thrombosis. OAC with vitamin K antagonists should be started as soon as LVT is identified, as first-line therapy and parenteral anticoagulation should be discontinued when effective therapeutic range with warfarin has been achieved (INR of 2–3). European and American guidelines stressing the efficacy of parenteral therapy with heparin; there are no randomized trials that have examined the efficacy of VKA anticoagulation compared with parenteral therapy. DOACs are attractive alternatives because of their potential efficacy and safety even though there is no trial that proves the effect of DOACs in LVT. Oral anticoagulation should be discontinued as soon as thrombus resolution has been established. Surgical removal of the LVT is an option for patients with high embolic risk, as in our patient. The high morbidity and mortality of this approach outweigh the benefits of performing surgery solely for the indication of LVT.

Hydraulic traits are not robust predictors of tree species stem growth during a severe drought in a wet tropical forest

Abstract Severe droughts have led to lower plant growth and high mortality in many ecosystems worldwide, including tropical forests. Drought vulnerability differs among species, but there is limited consensus on the nature and degree of this variation in tropical forest communities. Understanding species‐level vulnerability to drought requires examination of hydraulic traits since these reflect the different strategies species employ for surviving drought. Here, we examined hydraulic traits and growth reductions during a severe drought for 12 common woody species in a wet tropical forest community in Puerto Rico to ask: Q1. To what extent can hydraulic traits predict growth declines during drought? We expected that species with more hydraulically vulnerable xylem and narrower safety margins (SMP50) would grow less during drought. Q2. How does species successional association relate to the levels of vulnerability to drought and hydraulic strategies? We predicted that early‐ and mid‐successional species would exhibit more acquisitive strategies, making them more susceptible to drought than shade‐tolerant species. Q3. What are the different hydraulic strategies employed by species and are there trade‐offs between drought avoidance and drought tolerance? We anticipated that species with greater water storage capacity would have leaves that lose turgor at higher xylem water potential and be less resistant to embolism forming in their xylem (P50). We found a large range of variation in hydraulic traits across species; however, they did not closely capture the magnitude of growth declines during drought. Among larger trees (≥10 cm diameter at breast height—DBH), some tree species with high xylem embolism vulnerability (P50) and risk of hydraulic failure (SMP50) experienced substantial growth declines during drought, but this pattern was not consistent across species. We found a trade‐off among species between drought avoidance (capacitance) and drought tolerating (P50) in this tropical forest community. Hydraulic strategies did not align with successional associations. Instead, some of the more drought‐vulnerable species were shade‐tolerant dominants in the community, suggesting that a drying climate could lead to shifts in long‐term forest composition and function in Puerto Rico and the Caribbean. Read the free Plain Language Summary for this article on the Journal blog.

The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature.

Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS). We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews. Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.