Presence Of Intracardiac Thrombus Research Articles

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.

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.

Possibilities of computed and magnetic resonance imaging of the heart in patients with ­atrial fibrillation

Computed and magnetic resonance imaging of the heart has been widely used in recent years in patients with atrial fibrillation. They are used to determine the morphology of the heart, the presence of intracardiac thrombi, quantify the structures of the heart, thrombosis of intracardiac devices, determine tactics for surgical interventions, and other purposes. These methods of instrumental diagnostics can be used as an alternative to transesophageal echocardiography, which has a number of limitations and disadvantages compared to computed tomography and magnetic resonance imaging. Computed and magnetic resonance imaging of the heart are used to avoid invasiveness in the study of the heart, to improve the accuracy of measuring heart structures, to reduce the number of diagnostic methods used before various surgical interventions in patients with atrial fibrillation, and also, according to epidemic indications, as part of the prevention of the spread of coronavirus infection. In addition, magnetic resonance imaging allows to avoid radiation exposure to the patient. The review presents the results of studies, meta-analyses of pooled samples, as well as a description of the clinical possibilities of computed and magnetic resonance imaging of the heart in patients with atrial fibrillation. Publications on the use of these methods for visualization of thrombi in the left atrium and its appendage, in pulmonary vein ablation and occlusion of the left atrial appendage, as well as data on visualization of the residual flow around the occlusive device and thrombosis of intracardiac devices are presented. According to the results of a literature review, computed tomography and magnetic resonance imaging of the heart have similar or higher imaging capabilities compared to transesophageal echocardiography, as well as some advantages over it, primarily the non-invasiveness of the procedure. The works demonstrating the possibilities of computed tomography of the heart for the diagnosis of coronary heart disease in patients with atrial fibrillation are presented. In preparing the review, the literature search method in PubMed databases for the period 20132022 was used.

623 PERCUTANEOUS LEFT ATRIAL APPENDAGE CLOSURE AND TRANSCATHETER CEREBRAL EMBOLIC PROTECTION: TWO CASES REPORT

Abstract Introduction Percutaneous left atrial appendage closure (LAAC) in AF patients is not inferior to oral anticoagulation (OAC) in terms of systemic embolism. LAA Closure is usually contraindicated in presence of intracardiac thrombus, a condition far from uncommon. The feasibility and safety of transcatheter cerebral embolic protection (TCEP) has been reported in literature as a successful off – label option in retrieving embolic debris during percutaneous LAAC. We present two cases of Watchman Flex insertion in the setting of LAA thrombus and prophylactic use of TCEP. Cases report The first patient was an 88-year-old male with history of symptomatic AF and post – traumatic cerebral bleeding, who was referred to LAAC because of high risk of bleeding in using OAC. Transthoracic echocardiography (TTE) documented a severely dilatated left atrial and preserved left ventricular systolic function. Transesophageal echocardiography (TEE) revealed a “chicken wing” shaped LAA with spontaneous echo-contrast and sludge effect confirmed with echo-contrast medium “SonoVue”. ECG – gated cardiac CT (CCT) showed a LAA filling defect and confirmed the diagnosis of LAA thrombus. The second patient was a 75-year-old man with valvular permanent AF and history of multiple ischemic strokes despite of OAC therapy with Warfarin. TTE documented a dilated left ventricle with severely depressed ejection fraction; TEE revealed a “windstock” shaped LAA with incompletely distal opacification with echo-contrast medium “SonoVue”. Both patients were candidate to LAAC with concomitant use of CEPDs in the event of neurological complication. TriGUARD 3 cerebral protection (TG3, Keystone Heart) was deployed in the aortic arch through right femoral artery access before LAAC procedure. Following transseptal puncture Watchman Flex device (Boston Scientific, Marlborough, MA) was deployed without complications or residual peri-device leaks. At the end the TriGurad 3 device was retracted and no debris were noted at the post operatory inspection. The first patient was discharged afterward with daily acetylsalicylic acid 100 mg and Clopidogrel 75 mg and the second patient with daily acetylsalicylic acid 100 mg and Warfarin. Both patients underwent follow-up TEE at four weeks. Neither device – related complications nor thrombotic/hemorrhagic adverse events have been not reported so far. Discussion Both patients were at very high risk for stroke and bleeding. They were not theoretically candidate to LAAC because of intracardiac thrombus. The prophylactic use of TCEP (including TG3) has been reported in a small retrospective study by Tarantini et al. and in some case series. Procedures were always successful and uneventful. Moreover, small captured debris on the device on visual examination proved its efficacy. The use of TCEP has been mentioned even by Beneduce et al. as a safer and more feasible strategy in AF patients. Conclusion Prophylactic use of TCEP during The Watchman Flex device implantation is safe and feasible.

Capabilities of transesophageal echocardiography in patients with atrial fibrillation

Transesophageal echocardiography is widely used in clinical practice in patients with atrial fibrillation and it is mainly applied to determine the morphology of the heart, the presence of intracardiac thrombi, quantify the structures of the heart, as well as to determine the tactics for surgical interventions. Transesophageal echocardiography has an advantage over transthoracic echocardiography in visualizing the left atrium and left atrial appendage, common sites of thrombus formation in patients with atrial fibrillation. Due to the anatomical proximity of the esophagus to the heart, the transesophageal access avoids signal fading and incorrect interpretation of the study results. The possibilities of transesophageal echocardiography in patients with atrial fibrillation have expanded with the development of medical technology, and three-dimensional transesophageal echocardiography has become widespread. In recent years, the studies on the use of the transesophageal echocardiography in patients with atrial fibrillation during the coronavirus pandemic have been published. The review presents the results of studies, meta-analyzes of pooled samples, as well as clinical cases, demonstrating capabilities of transesophageal echocardiography in patients with atrial fibrillation. A brief history of the development of the method, work on the study of the technology features and capabilities of transesophageal echocardiography for pulmonary vein ablation, cardioversion, occlusion of the left atrial appendage in patients with atrial fibrillation, as well as studies on disadvantages of the transesophageal echocardiography and possible options for their elimination are presented. Comparison of the transesophageal echocardiography with transthoracic and intracardial echocardiography is also highlighted. In preparing the review, the literature search method in PubMed databases for the period 20122021 was used, as well as data from an earlier period to indicate the history of the method development.

Point-of-Care Resuscitative Echocardiography Diagnosis of Intracardiac Thrombus during cardiac arrest (PREDICT Study): A retrospective, observational cohort study

BackgroundPoint-of-care ultrasound (POCUS) has been previously studied in cardiac arrest, without definitive markers for futile resuscitation efforts identified. Intracardiac thrombus during cardiac arrest has not been systematically studied. Our objective was to describe the incidence of intracardiac thrombus and spontaneous echo contrast found during cardiac arrest. MethodsA two hospital, retrospective, observational cohort study of 56 cardiac arrest patients who were assessed with POCUS (between January 1st, 2017 to April 30th, 2020). Eligible studies were reviewed for echocardiographic findings (e.g. presence of intracardiac thrombus or spontaneous echo contrast), baseline patient demographics, cardiac arrest-related data, and clinical outcomes. Primary outcome was in-hospital mortality. ResultsFifty-six intra-arrest POCUS echocardiograms were identified (out of 738 out-of-hospital cardiac arrests). The median patient age was 63 years (interquartile range [IQR]: 51–72), with 25% female patients, and median Charlson Comorbidity Index score of 4 (IQR: 2–6). The incidence of intracardiac thrombus was 21 out of 56 patients (38%). Time-to-new thrombus formation during cardiac arrest was approximately 6 minutes (IQR: 2-–8). All patients with intracardiac thrombus during cardiac arrest had termination of resuscitation. ConclusionsIntracardiac thrombus is potentially common during out-of-hospital cardiac arrests and was observed more frequently in those in whom termination of resuscitation was recommended. However, this is only hypothesis-generating at this time, and further study is required to determine if the presence of intracardiac thrombus may be used as a potential marker of resuscitation futility.

Presence of Intracardiac Thrombus at the Time of Left Ventricular Assist Device Implantation Is Associated With an Increased Risk of Stroke and Death

BackgroundHeart failure predisposes to intracardiac thrombus (ICT) formation. There are limited data on the prevalence and impact of preexisting ICT on postoperative outcomes in left ventricular assist device patients. We examined the risk for stroke and death in this patient population. Methods and ResultsWe retrospectively studied patients who were implanted with HeartMate (HM) II or HM3 between February 2009 and March 2019. Preoperative transthoracic echocardiograms, intraoperative transesophageal echocardiograms and operative reports were reviewed to identify ICT. There were 525 patients with a left ventricular assist device (median age 60.6 years, 81.8% male, 372 HMII and 151 HM3) included in this analysis. An ICT was identified in 44 patients (8.4%). During the follow-up, 43 patients experienced a stroke and 55 died. After multivariable adjustment, presence of ICT increased the risk for the composite of stroke or death at 6-month (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.00–3.33, P = .049). Patients with ICT were also at higher risk for stroke (HR 2.45, 95% CI 1.14–5.28, P = .021) and death (HR 2.36, 95% CI 1.17–4.79 P = .016) at 6 months of follow-up. ConclusionsThe presence of ICT is an independent predictor of stroke and death at 6 months after left ventricular assist device implantation. Additional studies are needed to help risk stratify and optimize the perioperative management of this patient population.

Acute neurological complications in adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation support

BackgroundExtracorporeal life support has markedly progressed over the recent years to support patients with severe cardiac and pulmonary dysfunction refractory to conventional management. Many patients developed acute neurological complications while being supported with extracorporeal membrane oxygenation (ECMO). Our objectives were to study the frequencies and outcomes of CNS complications in adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and to study the risk factors of these CNS complications. We conducted a retrospective study including adult patients admitted to the cardiac critical care unit with cardiopulmonary instability and supported with VA-ECMO from January 2016 until December 2018 in a tertiary care hospital.ResultsAfter reviewing 231 patients with ECMO, 67 patients with cardiogenic shock supported with VA-ECMO were included. About 65.7% of the studied patients were supported after cardiothoracic surgeries. About 56.7% of the patients developed acute CNS events. According to brain CT imaging, ischaemic stroke was diagnosed in 14.9% and intracerebral haemorrhage (ICH) was diagnosed in 11.9% of patients while 16.4% of patients with CNS events had negative brain CT imaging. The SOFA score was significantly higher in the group with CNS events at ICU admission and after 48 hours . As compared to patients with ischaemic strokes, patients with ICH were younger with lesser BMI, had higher SOFA scores at admission and at 48 hours of ICU admission, had longer cardiopulmonary bypass and aortic cross clamping times and had more support with central than peripheral VA-ECMO. AF was more frequent in the group with CNS events especially in the ischaemic stroke subgroup. Presence of intracardiac thrombi was more frequent in the ischaemic stroke subgroup. There was no statistically significant difference between both groups regarding ECMO circuit thrombi. The use of IABP and presence of DM were more frequent in the ischaemic stroke subgroup. Patients with neurological events had hypoalbuminaemia and higher blood glucose and serum creatinine levels compared to those without CNS events. The peak lactate level and lactate after 24 hours of ECMO support were significantly higher in those with CNS events. Patients with ICH had significant thrombocytopenia and higher INR with more prolonged aPTT and PTT ratio than those with ischaemic stroke. Patients with neurological events had significant hospital mortality, more mechanical ventilation days and tracheostomy, AKI and haemodialysis compared to those without CNS events, but there were no significant differences between both groups regarding ECMO duration, ICU or post ICU stays nor 1 year mortality.ConclusionAcute neurological events are frequent in patients supported with VA-ECMO and associated with significant morbidity and hospital mortality. As compared to ischaemic stroke, ICH is more frequent in younger patients with lesser BMI, central VA-ECMO after cardiothoracic surgeries, thrombocytopenia, and coagulopathy. Our findings may have major implications for the care of patients requiring VA-ECMO.

P1312 Implications of a large atrial roof thrombus

Abstract Funding Acknowledgements No funding Introduction Rheumatic heart disease is the most common cause of mitral valve stenosis. Rheumatic valve disease presents a strong predisposing factor to intracardiac thrombi formation in the left atrium, particularly when there is a background of atrial fibrillation. The predominant location for thrombus creation is the left atrial appendage, due to its morphology, and rarely the free wall or roof of the left atrium. In either case, the presence of intracardiac thrombi in the left cardiac cavities poses a severe risk factor for systemic embolism which can prove detrimental for the patient leading to increased morbidity and mortality. Transesophageal echocardiography remains the gold standard for screening of the left atrium. Case presentation We present the case of a 72 year old woman who was admitted to the Emergency Department of our Hospital because of palpitations and progressive weakness over the last month. She had a known history of rheumatic mitral valve stenosis and chronic atrial fibrillation under standard anticoagulant treatment with acenocoumarol. Methods - Results: On admission, the patient was hemodynamically stable without signs of heart failure. The electrocardiogram revealed atrial fibrillation with a ventricular rate of approximately 135 bpm. Chest X-Ray did not demonstrate any signs of pulmonary congestion. Blood tests were normal, except from a subtherapeutic INR 1.3. Transthoracic echocardiography depicted a suspicious large echogenous mass located on the posterior wall of the left atrium. Furthermore, there was severe mitral valve stenosis with calcification of the mitral annulus as well as reduced mobility of the leaflets (Mitral Valve Area ∼0.8 cm2, Mean gradient = 15 mmHg) and mild aortic valve stenosis. The left ventricle had normal dimensions and good overall systolic function. Systolic pulmonary pressure was estimated at 50 mmHg. Transesophageal echocardiography confirmed the presence of a large echogenous mass (2,6 x 2,9 cm) located on the posterior wall of the left atrium between the right and left pulmonary veins as well as another mass at the left atrial appendage. Contrast echocardiography ensued, which revealed no absorption of the contrast medium by the mass thus suggesting a lesion with no vascularity, compatible with thrombus. Furthermore there was diffuse slow flow within the left atrium (smoke) indicating blood stasis. The patient was treated with a cardioselective beta blocker and combination of aspirin and acenocoumarol with a target INR of 2,5-3 and was referred for cardiothoracic consultation. Conclusion/Discussion: We describe a rare case of moderate mitral stenosis with presence of a large thrombus with mobile parts in an unusual location. In this setting the indication for surgery (mitral valve replacement) is upgraded since there is increased risk of thrombus detachment and debilitating systemic embolism. Abstract P1312 Figure.

Right Ventricular Thrombus and Tricuspid Valve Dysfunction in a Patient with Beh&amp;amp;ccedil;et’s Disease

Background: Behçet’s disease (BD) is a multisystemic, chronic inflammatory disorder with a broad range of manifestations including within the cardiovascular system. Cardiac involvement like intracardiac thrombus (ICT) and valvular involvement in BD are rarely seen entities and often associated with poor prognosis. Case Presentation: We present the case of a young patient with vascular-Behçet diagnosed by the presence of intracardiac thrombus in the right ventricle, unresponsive to medical treatment. Even though the intracardiac lesion was successfully treated by surgical excision, he presented a severe tricuspid dysfunction some years later due to the extension of fibrosis with no surgical therapeutic option. Conclusion: Intracardiac thrombosis is a rare but early manifestation of Behçet’s disease, which is difficult to diagnose and has a poor prognosis.

5201Intra-cardiac thrombus in patients undergoing ventricular tachycardia ablation. a computed tomographic scan study

Abstract Background Embolic event is one of the complications of VT ablation. This may be due to the presence of intra-cardiac thrombus before ablation. However, there is no clear consensus on how to rule out thrombus before the procedure. Objective We sought to examine the prevalence and risk factors of intra-cardiac thrombus with cardiac computed tomographic (CT) scan in patients undergoing scar-related VT ablation. Methods In absence of contra-indication, all patients undergoing scar-related VT ablation at our institution underwent contrast-enhanced cardiac CT within one week before ablation. 324 consecutive patients (292 male, 59±16 yo) have been included in this study. The etiology was ischemic cardiomyopathy (CMP) (n=191), arrhythmogenic right ventricular CMP (ARVC) (n=37), congenital CMP (n=11) or other CMP (n=85). LVEF was &lt;40% in 154 patients (48%). Results Intra-cardiac thrombus was diagnosed in 29 (9%) patients: in the left atrium (n=8), in the right atrium (n=1), in the left ventricle (n=15), in the right ventricle (n=3), in right and left atrium (n=1), and in left atrium and right ventricle (n=1). Moreover in 2, a bilateral pulmonary embolism was identified. The population with thrombus was older (65±12 vs 58±16 years, p=0,005), with more permanent atrial fibrillation (AF) (28% vs 8%; p=0.005). Patients with left ventricular (LV) aneurysm were at higher risk of thrombus 50% vs 3% (p&lt;0.001). The average CHADSVASC score was similar for both groups (2,5 vs 2,1; p=0.179). After matching for age and sex, only ischemic CMP and LV aneurysm were risk factors for thrombus. Because of arrhythmic storm, ablation was performed by epicardial approach only, in 5 patients with intra-ventricular thrombus and by retroaortic approach only, in 2 patients with LAA thrombus. No embolic event occurred during these procedures. Conclusion CT scans help eliminating intra-cardiac thrombus before VT ablation procedure. A high proportion of thrombus (9%) was identified. Whereas LV thrombus should systematically be ruled out before scar related VT ablation, in patients with AF, a LAA thrombus should also be eliminated as well as RV thrombus in patients with ARVC. Acknowledgement/Funding ANR-10-IAHU-04

Anticoagulation Therapy in Specific Cardiomyopathies: Isolated Left Ventricular Noncompaction and Peripartum Cardiomyopathy.

In 2 distinct entities, left ventricular noncompaction (LVNC) and peripartum cardiomyopathy (PPCM), routine anticoagulation therapy is often used in current practices. However, our systematic review showed that LVNC itself was not associated with the increase in thromboembolism event rates and therapeutic anticoagulation therapy should not be considered only for LVNC, unless there is risk factor for thromboembolism. Current literature justifies prophylactic therapeutic anticoagulation in LVNC with low left ventricular ejection fraction (EF < 40%) and/or atrial fibrillation. Although not specifically studied, the presence of intracardiac thrombi by echocardiography or other imaging studies should also prompt anticoagulation therapy. There is limited evidence available for the use of anticoagulation in patients with PPCM, but our systematic review showed that anticoagulation should be recommended only for patients with PPCM especially with an EF < 35% until EF is recovered, as well as for patients with PPCM treated with bromocriptine.

Subcutaneous ICD–A North Queensland Experience

Introduction: Subcutaneous implantable cardioverter defibrillators (S-ICD) are an attractive option over traditional transvenous devices as they avoid vascular complications, use less fluoroscopy, and avoid intra-cardiac leads. Their availability is increasing globally and we present our experience in North Queensland. Methods: We performed a retrospective review of patients who had an S-ICD inserted in Townsville Hospital. Hospital records and implant details were reviewed. Results: 12 patients had S-ICD implantation between January 2015 and February 2017. Mean age of 42(18-66), with 8 males. Indications included hypertrophic cardiomyopathy (3/12), channelopathies (3/12), idiopathic cardiomyopathy (3/12), ischaemic (2/12) and non-compaction cardiomyopathy (1/12). 7/12 were for primary and 5/12 for secondary prevention. All patients had QRS durations <120ms, no documented bradycardia, and an average LVEF of 46%. All procedures were done under GA using a 3-incision technique with 10 patients having satisfactory defibrillator threshold (DFT) testing. In two, DFT were contraindicated from the presence of intra-cardiac thrombus. Mean procedure time was 87mins (95%CI 53-121mins), with an average radiation dose of 20mGr. There were no peri-procedural complications and all were discharged within 48 hours post implantation. At an average of 9 months follow-up, there were no device related events, one traumatic dehiscence requiring pocket revision, one ED presentation with implantation site pain and no deaths. Conclusion: S-ICD is a safe and viable treatment for prophylaxis against sudden cardiac death. Our experience reveals excellent patient outcomes and support current evidence for its increasing use in a variety of cardiac diseases for the North Queensland community.

Right ventricular endomyocardial fibrosis (2013 Grover Conference series).

Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy of unknown origin, affecting predominantly the right side of the heart. Its highest prevalence is in poor regions of sub-Saharan Africa, where it is usually found in children and adolescents. In areas where it is endemic, EMF is a major cause of heart failure and premature death. EMF of the right ventricle has unique clinical, electrocardiographic, and echocardiographic signs. Several features of advanced disease are not fully understood, the most striking being the presence of severe ascites with little or no pedal edema. Echocardiography is the main diagnostic tool and supports management of the disease in most patients, as it allows assessment of the severity and extension of endocardial fibrosis, the quality of the right atrioventricular valve, and the presence of intracardiac thrombi. Pulmonary hypertension in the setting of right EMF is related to chronic thromboembolism, through the chronic thrombi present in the severely enlarged right atrium found in advanced disease. The management of right EMF is difficult. Treatment of symptomatic patients should be surgical. However, as the disease is usually detected in late stages, with severe and advanced lesions, surgery cannot be performed without a very high risk of death and complications. New surgical approaches addressing several components of the structural cardiac abnormalities have been attempted, with promising results. EMF remains one of the most neglected diseases worldwide, and research into its pathophysiological mechanisms will probably improve outcomes and alter the natural history of the disease. This requires improvement in the health systems in areas of endemicity as well as the design of international collaborative research projects.

Intracardiac thrombi in pulmonary embolism of a priori non high risk: therapeutic dilemma

Pulmonary embolism (PE) of a priori non high risk according to ESC guidelines, but coexisting with intracardiac thrombi is potentially a life threatening disease. The recommendations regarding therapy in such situations are not clear. We report two cases of PE with coexisting intracardiac thrombi. The 74 year-old woman was admitted after previous cardiac arrest in the course of PE with the presence of intracardiac thrombi in right ventricle. Due to lack of clinical improvement during heparin administration she was treated with thrombolysis. The 72 year-old obese woman with hypertension, diabetes and previous stroke with right-sided paresis was admitted after 2 episodes of loss of consciousness, with intracardiac thrombus in both right and left heart. Due to contraindications to both surgery and thrombolysis, she was treated with heparin. Both women recovered successfully. These cases illustrate the importance of individual treatment strategy.

Clinically Significant Thrombosis in Pediatric Heart Transplant Recipients During Their Waiting Period

Thrombosis is a serious complication of heart failure for which available data on pediatric patients are scarce. This report describes the frequency and risk factors of clinically significant thrombosis (CST) for children awaiting transplantation. A retrospective study analyzed a cohort of heart recipients with CST, defined by the presence of intracardiac thrombus by imaging, explant pathology, or symptomatic clinical event. Among the 123 patients in the study, 56 % were male and 44 % had congenital heart disease. The median age at transplantation was 6.6 years (range 0-30 years). The prevalence of CST was 12.2 % (15/123), and its incidence was 32.7 events per 100 patient-years. The thromboembolic event frequencies were 2.4 % and 6.5 events per 100 patient-years. The median interval from listing to CST was eight days (range 0-113 days). The median wait-list duration was 31 days (range 8-169 days) in the CST group versus 51 days (range 0-1,743 days) in the non-CST group. Inpatient status was statistically associated with CST (14 of 15 subjects were inpatients, p = 0.03). Inotropic support (p = 0.068) and United Network for Organ Sharing (UNOS) status 1 (p = 0.061) approached significance. Clinically significant thrombosis was common in this end-stage heart failure population. Until randomized clinical trial data are available, it may be reasonable to consider anticoagulation for children admitted with decompensated heart failure and listed as UNOS status 1.

Paradoxical Thromboembolism: A Trip Better Left Untraveled

Introduction Pulmonary embolism is a common sequela of deep vein thrombosis (DVT). Less well documented is the occurrence of DVT and its relationship to stroke via an intracardiac shunt such as a patent foramen ovale (PFO). We report a case of DVT and stroke in conjunction to the presence of intracardiac thrombus and a moderate-sized PFO. Methods This is a case study report of a 61-year-old woman with a previous medical history of hyperlipidemia only who traveled to Mexico from the Unites States. The trip included three long bus trips of 12, 13, and 14 hours in duration. This patient presented to a hospital in Mexico with severe headache and right-sided weakness. The patient was diagnosed and treated for left hemispheric stroke and eventually transported to our hospital in Houston, Texas, for further stroke evaluation and management. With the use of a Philips IE33 8 MHz linear array probe and multi-plane TEE probe as well as a Siemens Sequoia 4V phased array probe, we were able to safely and accurately diagnose and manage the patient's condition until intervention could be safely performed. Results Multiple diagnostic imaging tests were performed, including a bilateral lower-extremity duplex venous ultrasound, duplex carotid ultrasound, transthoracic and transesophageal echocardiograms, as well as computed tomography scans of the chest and brain. With the patient's current condition and symptoms as well as the collected findings, our test results indicated that a paradoxical thromboembolic event had most likely occurred. There was right lower-extremity DVT, bilateral pulmonary embolisms, and large and highly mobile thrombus within the right-side chambers of the heart that occasionally protruded through a moderate size patent foramen ovale of 0.9 cm. The left distal common carotid artery and internal carotid artery were found to be occluded, and initial computed tomography scan of the brain showed a large left middle cerebral artery distribution infarct. Conclusion Venous thromboembolic disease can cause stroke in the presence of an intracardiac shunt such as a PFO. The use of vascular and cardiac ultrasound examinations is critical in determining the etiology of cerebrovascular events. We document a rare case of combined DVT, pulmonary embolism, intracardiac thrombus, PFO, and extracranial carotid arterial occlusion. Although the prevalence of DVT and intracardiac shunts alone is high, it is unclear from the literature which patients would benefit from PFO closure.

Prospective, randomized comparison of two biphasic waveforms for the efficacy and safety of transthoracic biphasic cardioversion of atrial fibrillation

The purpose of this study was to determine if there is a difference in commercially available biphasic waveforms. Although the superiority of biphasic over monophasic waveforms for external cardioversion of atrial fibrillation (AF) is established, the relative efficacy of available biphasic waveforms is less clear. We compared the effectiveness of a biphasic truncated exponential (BTE) waveform and a biphasic rectilinear (BR) waveform for external cardioversion of AF. Patients (N = 188) with AF were randomized to receive transthoracic BR shocks (50, 75, 100, 120, 150, 200 J) or BTE shocks (50, 70, 100, 125, 150, 200, 300, 360 J). Shock strength was escalated until success or maximum energy dose was achieved. If maximum shock strength failed, patients received the maximum shock of the opposite waveform. Analysis included 141 patients (71 BR, 70 BTE; mean age 66.5 +/- 13.7. Forty-seven randomized patients were excluded because of flutter on precardioversion ECG upon blinded review (n = 25), presence of intracardiac thrombus (n = 7), or protocol deviation (n = 15). Groups were similar with regard to clinical and echocardiographic characteristics. The success rate was similar for the two waveforms (93% BR vs 97 BTE, P = .44), although cumulative selected and delivered energy was less in the BTE group. Only AF duration was significantly different between successful and unsuccessful patients. No significant complications occurred. Biphasic waveforms were very effective in transthoracic cardioversion of AF, and complication rates were low. No significant difference in efficacy was observed between BR and BTE waveforms. Impedance was not an important determinant of success for either biphasic waveform.

Antiphospholipid Syndrome Presenting as Intracardiac Thrombus With Pulmonary Embolism

The presence of antiphospholipid antibodies is associated with arterial and venous thrombosis. A young female with initial presentation of dyspnea and cough that lasted for days is reported. A computed tomographic scan of her chest and echocardiography showed features of thrombus formation over the right atrium, complicated with pulmonary thromboembolism. Antiphospholipid syndrome was diagnosed according to elevated activated partial thromboplastin time, high serum titers of anticardiolipin antibody, and the presence of intracardiac thrombus with pulmonary embolism. This thrombus was subsequently removed successfully with surgical intervention, and the patient's recovery was uneventful.

Usefulness of transesophageal echocardiography in unexplained cerebral ischemia

Two-hundred seventy consecutive patients with “unexplained cerebral ischemia” were studied with transesophageal echocardiography to determine the value of this test in identifying potential cardiac sources of cerebral embolism. The findings of this group were compared with those of 772 consecutive patients undergoing transesophageal echocardiographic evaluation for indications other than cerebral ischemia. This study also examined this group of patients with unexplained cerebral ischemia to determine differences in relation to underlying cardiac rhythm and patient age. Intracardiac thrombus, atrial septal aneurysm, patent foramen ovate, spontaneous left atrlal contrast and protruding debris in the thoracic aorta were found more often in patients with unexplained cerebral ischemia. Wall motion abnormalities of the left ventricle, as well as mild to moderate valvular lesions including mitral valve prolapse, were found to be similar in both groups. Spontaneous left atrlal contrast, as well as mild to moderate valvular abnormalities, were found more often in patients with atrial fibrillation (22% of the group with unexplained cerebral ischemia). However, the presence of intracardiac thrombus was no more frequent in patients with atrial fibrillation than in those with normal sinus rhythm. Patients aged >50 years were found to have atrial fibrillation and larger left atrial size more often than their younger cohorts, as well as a greater incidence of valvular abnormalities and left ventricular wall motion abnormalities. Mitral valve prolapse was seen more frequently in the younger cohort of patients.