Intracardiac Thrombus Research Articles

Trends in intracardiac thrombus formation in myocardial infarction patients after PCI: a nationwide analysis

Abstract Background Percutaneous coronary interventions (PCI) have become a crucial therapeutic option for myocardial infarction (MI) patients. However, the clinical outcomes and complications associated with PCI, especially in relation to intracardiac thrombus, remain a subject of concern. Purpose We aimed to examine the real-world clinical outcomes and temporal trends of in-hospital mortality and intracardiac thrombus among myocardial infarction patients treated with PCI between 2017 and 2020. Methods The National Inpatient Sample was queried from 2017 to 2020 to identify all adults with myocardial infarction (ST elevation and Non-ST elevation MI) who underwent PCI using the International Classification of Diseases, 10th Revision codes. The Cochran-Armitage test assessed the linear trend of in-hospital intracardiac thrombus and mortality. Multivariable regression analysis was conducted to assess the association of PCI with in-hospital mortality and intracardiac thrombus. The Charlson comorbidity index was used to adjust for confounders. Results are represented as adjusted odds ratios (ORs) with their respective 95% confidence intervals (CIs). Results Of the 1,394,650 patients who underwent PCI, 8,080 (0.58%) experienced intracardiac thrombus, with a mean age of 62, predominantly male (76%). Despite decreasing rates of PCI noted over this 4-year period (Figure 1). There was an upward trend in in-hospital intracardiac thrombus revealed over a 4-year period (trend: 0.54%, p < 0.001). PCI was associated with a yearly increase in intracardiac thrombus in 2018 in 0.54% of patients (OR = 1.36, 95% CI 1.2 to 1.6, p < 0.001). In 2019, 0.56% of patients experienced intracardiac thrombus (OR = 1.4, 95% CI 1.2 to 1.6, p = 0.001); in 2020, 0.72% of patients (OR = 1.8, 95% CI 1.6 to 2.1, p = 0.008), compared to 2017 (0.4%). Mortality rates for PCI and ICT patients were 6% in 2017 (OR 2.2, p < 0.001, 95% CI 1.4-3.2), decreased to 5% in 2018 (OR 1.8, p < 0.004, 95% CI 1.2-2.6) and 4.7% in 2019 (OR 1.6, p < 0.01, 95% CI 1.1-2.4), then rose to 6.6% in 2020 (OR 2, 95% CI 1.4-2.8) (Table 1). Overall, in-hospital mortality was 5.6% (OR = 1.6, 95% CI 1.3 to 1.9, p < 0.001) among patients who had intracardiac thrombus related to PCI. Conclusions Our findings indicate a significant increase in intracardiac thrombus rates among MI patients treated with PCI from 2017 to 2020, accompanied by a considerable risk of in-hospital mortality. These outcomes underscore the critical need for vigilant monitoring and enhanced management approaches in this patient demographic.Figure 1Table 1

In-hospital outcomes of ventricular tachycardia catheter ablation in the presence of intra-cardiac thrombus

Abstract Background Ventricular tachycardia (VT) catheter ablation in the presence of intracardiac thrombi was evaluated in very few studies. Objectives To investigate in-hospital outcomes of VT ablation in the presence of an intracardiac thrombus, in a large inpatient US registry. Methods Using the National Inpatient Sample (NIS) database, patients who underwent non-elective VT catheter ablations in the US between 2016 and 2019 were identified using ICD-10 codes. Sociodemographic, clinical data, in-hospital procedures and outcomes as well as in-hospital mortality were collected. In-hospital outcomes were compared using propensity score (PS) matching analysis with a 1:3 ratio between patients with and without intracardiac thrombus. Results A weighted total of 15,725 admissions for non-elective VT ablation were included in the study, of which 190 (1.2%) had a discharge diagnosis of intracardiac thrombus. Patients with intracardiac thrombus had a higher comorbidity burden and were more likely to have ischemic cardiomyopathy and a diagnosis of cardiac aneurysm. In PS analysis, the presence of intracardiac thrombus was significantly associated with higher rates of any in-hospital complications (42.1% vs 19.3%, P<0.009), driven by higher periprocedural cerebrovascular accident and vascular injury events. In-hospital mortality rates were not significantly different between the groups. Conclusions In patients undergoing non-elective VT ablation, intracardiac thrombus was associated with higher rates of in-hospital complications, but not higher in-hospital mortality. These findings suggest that intracardiac thrombus should not contraindicate VT ablation when deemed necessary, while efforts should be made to decrease potential complications.

Analysis of safety and outcome of use of NOAC in intracardiac thrombi over warfarin

Abstract Introduction Intracardiac clots occur in 15- 25% of patients post myocardial infarction and in patient with atrial fibrillation. It holds poor outcome if not treated with anticoagulation. Warfarin remains the drug of choice in such patients, however recently according to the newly published data, the European Society of Cardiology (ESC) has recommended non-vitamin K antagonist anticoagulant (NOAC) for intracardiac clots as a class 2A recommendation. There is no documented data in the region of the gulf regarding the use of NOAC in intracardiac clots. Aim We aim in this study to evaluate the use of NOAC in the treatment of intracardiac clots over warfarin, by studying the effectiveness, safety and associated complications. Methodology A retrospective cohort study from April 2017 to December 2023 was conducted of patient’s above 18 years old who have a documented intracardiac clot on echocardiography. The patient were grouped into patients discharged on NOAC and those discharged on warfarin. The participants were studied for resolution of clot and development of complication; death, bleeding and thrombosis. Results A total of 253 patients fulfilled the inclusion criteria. Out of which 45 ( 18%) patients were discharged on NOAC and 208 (82%) on warfarin. The two groups had similar demographics with equally mean age of 71 years old , 89% being males, 38% hypertensive and most common clot in the left ventricle in both groups. From those patients with documented follow up ( NOAC 45% average of 8 months, Warfarin 62% average of 7 months); 48% in the NOAC group had a documented resolution of the clot while 44% in the warfarin group had a documented resolution of the intracardiac clot.(p value of 0.7) The median resolution time in the NOAC group was 4 months while in the warfarin group 3.5 months. Bleeding occurred in 19% and mortality rate was 5% in NOAC group, while in the warfarin group 10% developed bleeding and mortality rate was 6%. Conclusion Our data pointed out the safety of NOAC as a reasonable alternative to warfarin inpatient with intracardiac clots emphasizing the ESC recommendation in this regards. We recommend a randomized studies to prove the superiority of NOAC as anticoagulation of choice in intracardiac thrombi.

Incidence, determinants, and impact of in-hospital complications during percutaneous patent foramen ovale closure

Abstract Introduction The incidence, types, determinants, and clinical impact of in-hospital complications after contemporary patent foramen ovale (PFO) percutaneous closure is unclear. Purpose To describe the incidence, types, determinants, and clinical impact of in-hospital complications after percutaneous PFO closure. Methods This study included consecutive patients undergoing PFO percutaneous closure for any indication in 18 centers in France and Italy from the ongoing AIR-FORCE registry. Periprocedural complications were collected, including death, bleeding, myocardial infarction (MI), supraventricular arrhythmia, pericardial effusion or tamponade, cardiac perforation, device embolization, intracardiac thrombus, venous thrombosis, atrioventricular block, brachial paraesthesia, oesophageal hematoma, and veno-arterial fistula. Determinants of periprocedural complications were evaluated using a logistic multivariate model. The clinical impact of periprocedural complications on cardiovascular events after discharge measured by the composite endpoint of death, stroke, transient ischemic attack, MI atrial arrhythmia, pulmonary embolism, deep veinous thrombosis, BARC ≥2 bleeding, or percutaneous or surgical re-intervention on the PFO) at longest follow-up was evaluated using a Cox model adjusted on age, sex, body mass index, diabetes mellitus, hypertension, dyslipidemia, and shunt severity prior to closure. Results We analyzed a total of 2,799 patients undergoing PFO closure with median age 50.7 [41.7-58.6] years and 57.9% male. A total of 109 (3.9% 95%CI 3.2%-4.7%) patients presented at least one in-hospital complication, the most frequent being supraventricular arrhythmia in 39 (1.4% 95%CI 1.0-1.9%) patients and BARC bleeding type ≥2 in 26 (0.9% 95%CI 0.6-1.4%) patients. Determinants of in-hospital complications were older age (per on year aOR 1.02 95%CI 1.01-1.04), diabetes mellitus (aOR 2.58 95%CI 1.36-4.89) and PFO closure for secondary prevention of an arterial embolic event (aOR 2.12 95%CI 1.18-3.82). With a median follow-up of 1.1 [0.3-3.1] years, the occurrence of an in-hospital complication was associated with an increased risk of cardiovascular events after discharge (aHR 1.90 95%CI 1.26-2.89) (Figure 1). Conclusions Although relatively rare, the occurrence of in-hospital complication during PFO percutaneous closure is associated with an increased risk of cardiovascular events in the year following the procedure.

Clinical presentation, risk factors and six-month outcomes in Ugandan women with peripartum cardiomyopathy: prospective case-control study

Abstract Background Peripartum Cardiomyopathy (PPCM) frequently affects women of African descent. There is scarcity of data pertaining to the clinical presentation and outcomes of PPCM patients in Uganda, particularly when employing modern diagnostic tools and adhering to guideline-directed medical therapy (GDMT). Purpose We aimed to delineate the clinical characteristics, echocardiographic findings, and 6-month outcomes among women in Uganda diagnosed with PPCM. Methods Prospective case-control design conducted from June 2022 to August 2023. We enrolled 80 PPCM cases and 80 matched controls. Inclusion criteria comprised: (i) peripartum state, (ii) signs and symptoms of HF, (iii) left ventricular (LV) ejection fraction ≤ 45%, and (iv) exclusion of alternative causes of HF. Controls were healthy women matched for age and parity. Over a 6-month period, enrolled PPCM cases were diligently monitored while on GDMT. All participants underwent a physical examination, 12-lead electrocardiography, and a detailed echocardiography incorporating global longitudinal strain measurements at both baseline and the 6-month follow-up. Results At baseline, amongst the cases, the mean age was 33.6 ± 6.6 years, mean parity was 3±2.1 pregnancies. HF onset occurred within 9.5±6.5 weeks post-delivery. A total of 20 (25.0%) cases presented in NYHA Class 4 with dyspnea as the predominant symptom in 79.95% of cases. Atrial fibrillation (AF) was observed in 2(2.5%) patients. In comparison with healthy controls, high gravidity (0.2±1.0; p<0.001) was identified as the only predictor of PPCM in this study. (Table 1) At 6-months follow up, the mean LV ejection fraction (LVEF) showed improvement from 35.7±-11.0% to 45.9 ± 15.7% (p<0.001) accompanied by a reduction in left ventricular diameter (LVD) from 6.1±0.7 cm to 5.5±1cm(p<0.001). At the 6-month follow-up, recovery (LVEF ≥ 50%) occurred in 37 cases (55%), and 52 (65%)patients were asymptomatic (NYHA Class 1) at the 6-month follow-up. Six-month mortality data were available for 5(6.3%) women, and one patient successfully underwent the insertion of an Implantable Cardioverter-defibrillator for recurrent Ventricular Tachycardia. Regarding GDMT, 55 participants received Bromocriptine as part of their medication. Twenty(25%) patients received anticoagulation for AF(n=2) or intracardiac thrombus (n=6, 1.67%) (Figure 1) resulting in 2(2.5%) strokes within the 6-month follow-up. Conclusion The current study demonstrated a comparable mortality rate on GDMT, aligning with contemporary global studies at 7.5%. The observed high thrombus burden in patients may indicate suboptimal adherence to anticoagulation therapy. While the incidence of PPCM remains undefined in Uganda, the primary predisposing factor identified was high gravidity. A noteworthy proportion of patients exhibited incomplete LV recovery, suggesting the need for larger studies to comprehensively define the maternal and fetal outcomes in Uganda.Figure 1Table 1

Increased risk of stroke in non-rheumatic valvular disease associated with antiphospholipid syndrome (APS): a US nationwide study 2017-2019

Abstract Introduction Antiphospholipid syndrome (APS) is an autoimmune syndrome characterized by the presence of antiphospholipid autoantibodies, arterial and venous thrombosis, recurrent pregnancy loss and thrombocytopenia. Cardiac manifestations are also common which include coronary artery disease (CAD), non rheumatic valvular heart disorders (NRVHD), myocardial dysfunction, intracardiac thrombi and pulmonary hypertension. Valvular lesions occur likely due to immune complex deposition on the valves, causing fibrosis, calcification and subsequently valvular deformities. Literature review suggests prevalence of NRVHD in APS population is 30% and left sided valves are more involved than right. An increased risk of stroke has also been seen in APS patients with valvular disorders. Purpose Studies report variations in incidence of NRVHD in association with APS. To estimate the prevalence of NRVHD and their correlation with APS, we conducted a retrospective database analysis of hospitalizations across the United States. Additionally we investigated whether this association indicates a increased risk of ischemic stroke in this specific subpopulation. Methods The national inpatient sample (NIS) from 2017-2019 was queried for adult patients (age>18 yrs) admitted with a primary or secondary diagnosis of APS. These patients were stratified for different NRVHD including tricuspid stenosis, tricuspid insufficiency, pulmonary stenosis, pulmonary regurgitation, mitral stenosis, mitral insufficiency (MI), aortic stenosis (AS), and aortic regurgitation. Baseline risk factors and cardiac complications were compared. Multiple regression analysis was performed to study the association of NRVHD with stroke as the primary outcome in the subpopulation of APS hospitalizations. Results A total of 567600 adult patients hospitalized with diagnosis of APS were identified from the NIS 2017-2019 database. Among those, 33,095 had NRVHD with a mean age of 69 years. Of these, prevalence of males was 52.41% compared to females of 47.59%. In the cohort of APS, patients with NRVHD had a higher prevalence of coronary artery disease (43.78% vs 20.41%), diabetes mellitus (30.65% vs 27.56%), prior stroke (10.42% vs 7.78%) than those without valvular disorders. Among the APS population the most prevalent NRVHD were mitral insufficiency (MI), 2.45% and aortic stenosis (AS), 2.13%. In the cohort of NRVHD in APS hospitalizations, the odds of stroke was found to be 1.3 times higher with statistical significance (confidence interval (CI): 1.13-1.48, p <0.001) adjusted for relevant clinical and demographic risk factors such as tobacco abuse, CAD, diabetes mellitus, prior stroke. Conclusion This study shows 6.2% prevalence of NRVHD in APS population, of which MI and AS were common. NRVHD is also associated with higher odds of stroke in APS. Further studies are warranted in identifying the risk of stroke with NRVHD in APS population and emphasizing the need for early detection.

Penumbra Indigo® system to safely remove intracardiac thrombus in a 7-month-old infant with severe immunodeficiency disorder.

We report on a 7-month-old boy (4.2 kg/60 cm) with severe immunodeficiency disorder and bacterial septicaemia who was referred for an infected atrial thrombus secondary to a jugular central line. The echocardiogram showed a teardrop-shaped thrombus with a wide base adherent to the interatrial wall and a flimsy tail moving freely in the right atrium. Chest CT scan showed multiple lesions in both lungs consistent with infected micro-thrombi. The thrombus increased in size despite 2 weeks of antibiotics and anticoagulation. We applied the Indigo® Lightning® 7 aspiration system from Penumbra® (Alameda, USA) and removed percutaneously the thrombus under transoesophageal ultrasound and biplane fluoroscopic guidance. At 6 weeks of follow-up, the patient is alive, under enoxaparin with no procedure-related complication.

Cardiac CT vs Echocardiography for Intracardiac Thrombus Detection in Ischemic Stroke: A Systematic Review and Meta-Analysis of 43 Studies.

Ischemic stroke, a leading cause of mortality, necessitates understanding its mechanism for effective prevention. Echocardiography, especially transesophageal echocardiography (TEE), is the gold standard for detection of cardiac sources of stroke including left atrial thrombus, although its invasiveness, operator skill dependence, and limited availability in some centers prompt exploration of alternatives, such as cardiac CT (CCT). We conducted a systematic review and meta-analysis assessing the ability of CCT in the detection of intracardiac thrombus compared with echocardiography. We searched 4 databases up through September 8, 2023. Major search terms included a combination of the terms "echocardiograph," "CT," "TEE," "imaging," "stroke," "undetermined," and "cryptogenic." The current systematic literature review of the English language literature was reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. We assessed risk of bias using the QUADAS-2 tool and used random-effects meta-analysis to calculate different diagnostic metrics. The meta-analysis investigating CCT vs echocardiography for intracardiac thrombus detection yielded a total of 43 studies of 9,552 patients. Risk-of-bias assessment revealed a predominantly low risk of bias in the flow and timing, index test, and patient selection domains and a predominantly unclear risk of bias in the reference standard domain. The analysis revealed an overall sensitivity of 98.38% (95% CI 89.2-99.78) and specificity of 96.0% (95% CI 92.55-97.88). Subgroup analyses demonstrated that delayed-phase, electrocardiogram-gated CCT had the highest sensitivity (100%; 95% CI 0-100) while early-phase, nongated CCT exhibited a sensitivity of 94.31% (95% CI 28.58-99.85). The diagnostic odds ratio was 98.59 (95% CI 44.05-220.69). Heterogeneity was observed, particularly in specificity and diagnostic odds ratio estimates. CCT demonstrates high sensitivity, specificity, and diagnostic odds ratios in detecting intracardiac thrombus compared with traditional echocardiography. Limitations include the lack of randomized controlled studies, and other cardioembolic sources of stroke such as valvular disease, cardiac function, and aortic arch disease were not examined in our analysis. Large-scale studies are warranted to further evaluate CCT as a promising alternative for identifying intracardiac thrombus and other sources of cardioembolic stroke.

In-Hospital Outcomes of Ventricular Tachycardia Catheter Ablation in the Presence of Intra-Cardiac Thrombus.

Ventricular tachycardia (VT) catheter ablation in the presence of intracardiac thrombi was evaluated in very few studies. To investigate in-hospital outcomes of VT ablation in the presence of an intracardiac thrombus, in a large inpatient US registry. Using the National Inpatient Sample (NIS) database, patients who underwent non-elective VT catheter ablations in the United States between 2016 and 2019 were identified using ICD-10 codes. Sociodemographic, clinical data, in-hospital procedures, and outcomes as well as in-hospital mortality were collected. In-hospital outcomes were compared using propensity score (PS) matching analysis with a 1:3 ratio between patients with and without intracardiac thrombus. A weighted total of 15,725 admissions for non-elective VT ablation were included in the study, of which 190 (1.2%) had a discharge diagnosis of intracardiac thrombus. Patients with intracardiac thrombus had a higher comorbidity burden and were more likely to have ischemic cardiomyopathy and a diagnosis of cardiac aneurysm. In PS analysis, the presence of intracardiac thrombus was significantly associated with higher rates of any in-hospital complications (42.1%vs. 19.3%, p<0.009), driven by higher periprocedural cerebrovascular accident and vascular injury events. In-hospital mortality rates were not significantly different between the groups. In patients undergoing non-elective VT ablation, intracardiac thrombus was associated with higher rates of in-hospital complications, but not higher in-hospital mortality. These findings suggest that intracardiac thrombus should not contraindicate VT ablation when deemed necessary, while efforts should be made to decrease potential complications.

Cardiac thrombus in acute ischemic stroke: impact on endovascular thrombectomy utilization

Cardiac embolism plays a very significant role in acute ischemic strokes (AIS), constituting approximately one-third of cases. The origin of these emboli often stems from intracardiac thrombi in the left atrium or left ventricle. Utilizing the National Readmission Database from 2016 to 2019, we investigate the prevalence of cardiac thrombi in AIS patients and explore their potential correlation with endovascular thrombectomy (EVT) utilization, and mortality rates. Among 1,272,456 AIS patients, 0.6% had concurrent cardiac thrombus, with an increasing trend observed over the study period (P value < 0.001). The cardiac thrombus cohort showed a higher prevalence of comorbidities such as congestive heart failure and atrial fibrillation. After propensity-score matching, groups were well-balanced in terms of baseline characteristics. Patients within the cardiac thrombus cohort experienced a longer hospital stay (median 5 days vs. 3 days), but no significant difference in mortality was noted. Importantly, the cardiac thrombus cohort demonstrated a higher frequency of EVT utilization, suggesting a link to larger vessel occlusions. Despite matching based on atrial fibrillation, the EVT utilization in the cardiac thrombus cohort remained high, highlighting a significant association. While 30-day readmission rates were comparable, cardiac thrombus patients faced a higher risk of gastrointestinal bleeding and hemorrhagic stroke, likely attributed to anticoagulation use. Limitations include potential miscoding in the administrative database and a lack of detailed imaging findings. In conclusion, this study highlights the increased likelihood of EVT in AIS patients with cardiac thrombus, possibly indicative of larger vessel occlusion associated with cardiac thrombus.

Acute Vascular Complications of VA-ECMO in COVID-19 Patients. Does COVID-19 Affect the Outcome?

Extracorporeal membrane oxygenation (ECMO) through the femoral artery and vein can lead to significant vascular complications. We retrospectively studied the acute vascular complications of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in COVID-19 patients compared to non-COVID patients during the period from January 2020 to July 2023. Seventy-eight patients underwent VA-ECMO for various indications from January 2020 to July 2023. The studied patients had a mean age of 59.6 ± 6.9 years for non-COVID patients (38 patients), and 62.2 ± 7.6years for COVID patients (40 patients), with a P = 0.268. In non-COVID patients, The baseline characteristics were similar in both groups. The primary indications for ECMO were cardiac diseases, followed by respiratory failure (78.9% vs 10.5%). Conversely, in COVID patients, respiratory failure due to COVID-19 infection was the main indication (45% vs 40%). The overall incidence of general complications, including cerebrovascular stroke, acute kidney injury, intracardiac thrombi, and wound infection, was comparable in both groups (31.6% vs 45%). The overall incidence of vascular complications in both groups was 33.3%. Ipsilateral acute lower limb ischemia occurred in 5.3% vs 10% of non-COVID and COVID patients, respectively. Thrombosis of the distal perfusion catheter (DPC) occurred in 10.5% vs 15%, respectively. During the COVID-19 pandemic, an increasing number of patients required VA-ECMO due to associated respiratory failure. Patients undergoing VA-ECMO are at high risk of developing various vascular complications. COVID-19 significantly increases the risk of acute limb ischemia and distal perfusion catheter thrombosis in both upper and lower limbs. However, other VA-ECMO-related vascular complications are comparable between COVID-19 and non-COVID patients.

A case of successful surgical treatment of left ventricular thrombus associated with acute myocardial infarction by Impella combined with extracorporeal membrane oxygenation approach.

The mortality rate in patients with heart failure complicated by cardiogenic shock following acute myocardial infarction (AMI) remains high, prompting research on mechanical circulatory support. Improved mortality rates have been reported with the early introduction of EcMELLA (Impella combined with extracorporeal membrane oxygenation, ECMO). However, clear indications for this treatment have not been established, given the associated risks and limitations related to access routes. Left ventricular thrombosis is traditionally considered a contraindication for Impella use. A 74-year-old man without specific medical history or coronary risk factors was diagnosed with Forrester IV heart failure due to cardiogenic shock complicated by AMI and left ventricular thrombosis. The patient underwent emergency coronary artery bypass surgery, intracardiac thrombus removal, and Dor surgery. Following cardiopulmonary bypass, ongoing heart failure was observed, necessitating the implementation of EcMELLA for circulatory support. Preoperative computed tomography showed that the bilateral subclavian arteries were too narrow (< 7mm) and anatomically unsuitable for traditional access methods. Thus, we introduced a single-access EcMELLA 5.5, through which the Impella was introduced and veno-arterial-ECMO blood was delivered from a single artificial vessel anastomosed to the brachiocephalic artery. The patient was weaned off veno-arterial-ECMO and extubated on postoperative day 3. By postoperative day 14, improved cardiac function allowed for Impella removal. The patient was discharged on postoperative day 31 with improved ambulation; thereafter, the patient returned to work. Thus, the single-access EcMELLA5.5 treatment strategy combined with Dor procedure was effective in left ventricular thrombosis in patients with heart failure with cardiogenic shock complicated by AMI.

Aggressive Synchronous Papillary and Likely Follicular Thyroid Carcinomas in a Patient with Graves’ Disease

We report a case of an uncommonly aggressive presentation of the rare entity of synchronous papillary (PTC) and follicular thyroid carcinomas (FTC) in a 67-year-old woman initially presenting with thyrotoxicosis from Graves’ disease. She was found to have two thyroid nodules with extensive intra-cardiac tumour thrombus, symptomatic left pelvis bony metastasis with pathological fracture, pulmonary metastases and mediastinal lymph node metastases. Further investigations suggested a diagnosis of synchronous papillary and metastatic follicular thyroid cancer. Treatment with radical surgery followed by adjuvant therapeutic radioiodine ablation was proposed, but the patient declined all forms of cancer-specific therapy and was elected solely for a palliative approach to treatment. We discuss the diagnostic considerations in arriving at the diagnosis of synchronous thyroid malignancy – in this case the clear features of PTC and the strong probability of FTC due to invasiveness and metastatic follicular lesions. This case underscores potential limitations of the ACR TI-RADS system, notably with certain ultrasonographic features suggesting malignancy that might not be adequately captured. Notably, the aggressive presentation of DTC in this case may be contributed by the concurrent presence of Graves’ Disease, suggesting heightened vigilance when assessing potential thyroid malignancies in such patients.

The Consequences of a Heart Condition: Acute Stroke and Limb Ischemia Secondary to Massive Intracardiac Thrombus in a Young Female with Dilated Cardiomyopathy

Background: Dilated cardiomyopathy (DCM) is associated with the increased occurrence of left ventricular (LV) thrombosis caused by cardiac dysfunction. This condition is associated with significant mortality and morbidity because of its significance as a potential source of systemic emboli. We are reporting a case of Acute Stroke and Limb Ischemia in a Young Female Patient with DCM. Case Illustration: A 20-year-old female was referred to our hospital due to pain in her right lower extremities and weakness in her right limb. She had been diagnosed with peripartum cardiomyopathy five years earlier. A general physical examination found her right lower limbs to be cold and pulseless. A neurological examination revealed hemiparesis involving the right side of her body. The chest radiograph showed cardiomegaly. Electrocardiography indicated sinus rhythm with LVH. The transthoracic echocardiograms revealed significant LV systolic failure with a massive thrombus at LV. The Duplex ultrasound showed a thrombus at the right dorsal pedis artery, and a head CT scan revealed an acute infarct. The patient was started on heparin and bridged with warfarin 5mg orally daily, and she was uneventfully discharged after one week. Conclusion: DCM had been associated with thrombosis, stroke, and an increased risk of thromboembolism. Previous studies had documented decreased thromboembolic events due to administering anticoagulants. Keyword: Acute Stroke, Dilated Cardiomyopathy, Limb Ischemia, Massive Intracardiac Thrombus.

The Consequences of a Heart Condition: Acute Stroke and Limb Ischemia Secondary to Massive Intracardiac Thrombus in a Young Female with Dilated Cardiomyopathy

The Consequences of a Heart Condition: Acute Stroke and Limb Ischemia Secondary to Massive Intracardiac Thrombus in a Young Female with Dilated Cardiomyopathy

Computed tomography imaging-based radiologic evaluation of pulmonary artery thrombosis in a series of patients with Behcet's disease.

Pulmonary artery involvement is a severe complication of Behcet's disease (BD). Although venous thrombosis is common in BD, pulmonary embolism is considered to be rare because the inflammatory nature makes the thrombi strongly adherent to the venous walls. This study aimed to define the radiological characteristics of pulmonary artery thrombosis (PAT) on computed tomography (CT) imaging in BD patients. We retrospectively evaluated 165 BD patients with vascular involvement. Among the patients with venous involvement (n = 146), we identified 65 patients who had undergone thorax CT imaging previously. Fourteen patients who were diagnosed with PAT were included in the study. Expert radiologists re-evaluated the patients' initial and control thorax CT scans, classified the PAT as acute or chronic based on their radiological features. The patients' median age was 35 (min-max: 15-60) years at the time of the initial CT scan, and nine were male. Twelve (85.7%) patients were symptomatic at the time of CT evaluation. Upon re-evaluating the thorax CTs, acute PAT was diagnosed in six (42.8%); chronic PAT was detected in eight (57.1%) patients. Two patients with chronic PAT also had acute PAT. Pulmonary artery aneurysms were present in three (21.4%) patients, and intracardiac thrombus was found in three (21.4%) patients. A significant number of BD patients with venous involvement had radiological findings consistent with acute PAT potentially due to pulmonary emboli in this study. The clinical importance of these lesions has to be defined with future studies.

Endovascular thrombectomy provides durable, symptomatic relief in iliocaval tumor thrombosis

Iliocaval venous tumor thrombus is a morbid condition associated with chronic venous stasis, lower extremity edema/pain, extensive thrombus burden and high mortality secondary to critical flow obstruction, intracardiac thrombus extension and tumor embolization. Typically resistant to medical therapy, management is primarily surgical, presenting challenges for medically complex patients with widespread or end-stage disease. Mechanical or aspiration thrombectomy represents an appealing treatment strategy but data are lacking. We performed a single-center, 10-year, retrospective review of patients with pathology-confirmed, iliocaval tumor thrombus who underwent thrombectomy. 14 patients met inclusion criteria and were managed by 18 procedures over this period. The most common malignancy was renal-cell carcinoma (n=7; 50%); other types included germ cell (n=2; 14%), other genitourinary (n=2; 14%), neuroendocrine (n=1; 7%), soft tissue (n=1; 7%), and skin cell malignancies (n=1; 7%). All patients had thrombus involving the distal inferior venous cava (IVC), 50% had bilateral iliac involvement and 29% atrial involvement. Common indications were venous obstruction symptoms (n=11; 65%) and evidence of embolism (n=6; 35%). All patients tolerated the procedures without acute complication. The technical success rate was 94%, with marked improvement of flow and reduction in thrombus burden, and 79% had subjective symptomatic improvement. All patients survived for >2 weeks and 50% had long-term survival of >1 year, with 86% of these patients having renal-cell carcinoma (RCC). Three patients underwent multiple thrombectomies within days to weeks, with ultimate symptomatic improvement. Overall, our study results suggest mechanical or aspiration thrombectomy as a safe and efficacious treatment for patients with iliocaval tumor thrombus.

A case of neuro-Behcet's disease complicated with intra-cardiac thrombosis

Intra-cardiac thrombus is an unusual and rare complication of Behcet’s (BD) with poor prognosis. A 32-year-old man with a history of mouth and genital ulcers since 12 years ago was admitted to the neurology ward with complaints of headache and fever. Two years ago, the patient suffered from hydrocephalus due to cerebral vein thrombosis and a cerebral shunt was implanted for him. The patient was diagnosed with BD and was treated with glucocorticoids and cytotoxic drugs. During current hospitalization, with the diagnosis of shunt infection, the patient was treated with broad-spectrum antibiotics and the shunt was removed. On the 10th day of hospitalization, he developed cough and palpitation without dyspnea. Echocardiography showed a 2.5 × 4.7 mm mass in the right ventricle, tricuspid regurgitation and pulmonary arterial pressure of 32 mmHg. On computed tomography of the chest, the lung parenchyma was normal, but extension of the thrombus into the main pulmonary artery was reported.

AngioVac Procedures: Integration of cardiac surgeon and anesthesiologist-led transesophageal echocardiography: A preliminary report

IntroductionThe AngioVac system is a novel, minimally invasive, endovascular technique used to evacuate intravascular or intracardiac vegetation or thrombus. Although most AngioVac procedures are currently performed by interventionalists, this innovative procedure has been gaining attention among the surgical and anesthesia communities. MethodsWe retrospectively reviewed all patients who underwent the AngioVac procedure performed by a cardiac surgeon between August 2019 and December 2022. Fellowship-trained cardiac anesthesiologists operated TEE to navigate the AngioVac cannula during the procedure. The stored TEE images were retrospectively reviewed and independently analyzed by two cardiac anesthesiologists with specific focus on TEE-guided navigation of the AngioVac cannula towards the aspiration target. ResultsEleven patients underwent the AngioVac procedure during the study period. In nine cases, the majority of the vegetation or thrombus was successfully aspirated. In two cases, incomplete aspiration was attributed to the mass burden being too large, firm, and chronic in etiology. Worsening tricuspid regurgitation (TR) was identified in three of the 11 cases. Intraoperative TEE provided the cardiac surgeon with simultaneous display of the AngioVac cannula shaft, its tip, and aspiration target, as well as real-time assessment of TR, facilitating the minute movements essential for successful outcomes. ConclusionsThis study details our experience and the effectiveness of the AngioVac system for treating soft, intracardiac vegetation or thrombus in a minimally invasive manner. Experienced cardiac anesthesiologists have the skillsets and knowledge to provide optimal live TEE imaging necessary for successful maneuvering of the AngioVac cannula.

Ultrasound Rounds: Intraoperative Point-of-Care Ultrasound Identifies Intracardiac Thrombus and Pulmonary Embolism Allowing for Alteration in Surgical Management.

Most of the cases demonstrating describing acute findings using point-of-care ultrasound (POCUS) have been described in emergency medicine and critical care medicine. While the use of POCUS has become more prevalent in anesthesia practice, documentation of acute findings resulting in alteration in management based on real-time ultrasound findings during pediatric anesthesia remains limited. This case highlights the use of POCUS during cardiopulmonary collapse occurring during correction of neuromuscular scoliosis. POCUS excluded the presumed diagnosis of venous air embolism and identified an intracardiac thrombus leading to the diagnosis and treatment of pulmonary embolism.