Recurrent Embolism Research Articles

Case Report: Acute arterial occlusion of the right lower extremity due to left atrial invasion from pulmonary metastases of thyroid cancer

Cardiac metastases of thyroid cancer are rare. The most common metastatic route is through lymphatic or hematogenous spread to the right side of the heart. Direct invasion of metastases from other adjacent organs to the left side of the heart is even rarer. In many cases, the disease progresses asymptomatically, and symptoms appear only when it is already fatal. A 68-year-old woman underwent total thyroidectomy and right-side lymph node dissection for papillary thyroid cancer and multiple lung metastases 7 years previously. The patient was referred to our hospital due to sudden pain in the right lower extremity and motor disturbance. Computed tomography revealed acute arterial occlusion of the right lower extremity due to tumor dispersal from a left atrial invasion caused by multiple pulmonary metastases of thyroid cancer, and only emergency thrombectomy was performed. Although blood flow was restored, the patient died of respiratory failure 2 months after the procedure. Radical resection is considered difficult in cases of direct invasion of metastases from other adjacent organs because multiple metastases have often already occurred. Therefore, in the terminal stage, it might be too invasive to resect a tumor only to prevent embolism recurrence. The treatment strategy should depend on the patient's prognosis and choice.

Pulmonary Embolism and the Impact of Concomitant Deep Vein Thrombosis on Outcomes Among Cancer Patients

Intro: Venous thromboembolism (VTE) is a common cause of death among cancer patients, second only to cancer progression. Identifying factors predicting worse outcomes among cancer patients with VTE would be useful clinically. For cancer patients with pulmonary emboli (PE), it remains unclear whether concomitant leg deep vein thrombosis (DVT) as a source for further embolization adversely impacts this risk. The aim of this project was to determine the impact of residual DVT on adverse outcomes among cancer patients suffering acute PE. Methods: Consecutive patients with confirmed acute PE (March 1, 2013 - June 30, 2021) underwent ultrasound (US) imaging and were divided into two groups depending on the presence or absence of leg DVT. PE severity was classified based on AHA criteria. Patients were followed prospectively for VTE recurrence, major and clinically relevant non-major bleeding (CRNMB) and all-cause mortality. Results: Over the study interval, 1,035 cancer patients with PE were enrolled (Table 1). Of these, 375 (36.2%) had leg DVT confirmed by US. Patients with leg DVT were older (64.2 vs 61.4 years, p = 0.01), heavier (90.2 vs 85.1 kg, p <0.001), with lower metastatic disease prevalence (49.1% vs 57.1%, p = 0.01) compared to those without leg DVT. Cancer type distribution also differed between groups. PE patients with DVT more often had prostate, genitourinary, and hematologic cancers while those without DVT more often had pancreatic and breast cancers. Patients with DVT more often had symptomatic PE (48.2% vs. 35.9%, p < 0.001), massive (2.9% vs 0.5%, p < 0.001), and submassive (22.0% vs 7.6%, p < 0.001). Patients with DVT more often received unfractionated heparin (39.5% vs 18.7%, p < 0.001) whereas those without DVT were more frequently treated with low molecular weight heparin (57.5% vs. 44.3%, p <0.001), and apixaban (16.4% vs. 11.7%, p < 0.05). Anticoagulant duration, VTE recurrence, major bleeding and CRNMB were similar between groups (Table 2). Conclusion: Among a large cohort of cancer patients with pulmonary emboli, significant clinical and cancer specific differences exist comparing those with and without leg DVT.While theoretically increasing the risk of recurrent embolization, the presence of residual DVT does not appear to adversely impact important outcomes among cancer patients adequately treated with anticoagulation.

Should we add antiplatelet agents to current deep venous thrombosis treatments? A Cochrane Review summary with commentary.

Venous thromboembolism (VTE) is an important complication in rehabilitation practice despite preventive measures. The management can be complicated because patients may have co-existing cardiovascular comorbidities. To assess the effects of antiplatelet agents in addition to current best medical practice (BMP) compared to current BMP (with or without placebo) for the treatment of deep venous thrombosis (DVT). A summary of the Cochrane Review by Flumignan et al. (2022), with comments from a rehabilitation perspective. The review included six studies with 1625 eligible participants, with data up to 37.2 months of follow-up. When used after standard initial treatment with anticoagulants, antiplatelet agents such as aspirin in addition to BMP, may reduce recurrence of DVT or pulmonary embolism, when compared to BMP plus placebo in a chronic DVT setting and there may be a lower risk for post-thrombotic syndrome in patients with acute DVT. There is no clear difference in side effects, major bleeding, or pulmonary embolism (PE) with the use of antiplatelet agents. Adding antiplatelet agents to standard anticoagulation treatment in patients with VTE could provide benefit without increasing risks in selected patient groups. However, high quality studies with a long-term follow up are needed, including patients in rehabilitation settings.

Investigation of Plasminogen Activator Inhibitor-1 (PAI-1) 4G/5G promoter polymorphism and other thrombophilia genes in patients with acute pulmonary embolism

Abstract Background Venous thromboembolism (VTE) is a serious threat to life and health, commonly known as the silent killer. Recent study has found that VTE is a polygenetic disease and more than 60% of deep vein thrombosis risk is influenced by genetic factors [1]. PAI-1 is a serine protease with negative feedback to fibrinolysis, activating and inhibiting coagulation [2]. The aim of this study was to elucidate the clinical impact of the PAI-1 4G/5G polymorphism and other thrombophilia in patients with acute PE. Methods A total of 58 subjects with acute PE and 60 healthy controls, were recruited in Institute of Cardiology. The accuracy of the RT-PCR method for detecting F5 G1691A (FVL) and PAI-1 4G/5G polymorphisms was evaluated by using sequencing method as the gold standard. Moreover, the association of the PAI-1 4G/5G polymorphism with susceptibility, treatment efficacy and recurrence status were explored. Eventually, we evaluated the association with inherited thrombophilia genes, such as the coagulation Factor V Leiden, prothrombin G20210A, FGB-455 G/A and methylenetetrahydrofolate reductase C677T and 1298 A/C. Results It was noted that the vast majority of patients with acute PE (87.9%) present polymorphism in the PAI-1 gene (29.3% homozygous (4G/4G) and 58.6% heterozygous (5G/4G)). Eleven patients out of 58 (19% of patients) showed factor V Leiden mutation and 19 patients out of 58 (32,7% of patients) showed mutation in FGB-455 G/A (2 homozygotes); MTHFR C677T gene mutation was found in 55,2%, while prothrombin 20210A gene mutation was presented in 6 patients (10.3% of patients). Nine patients (15,5% of patients) presented with chronic complication of VTE and 38.7% of patients showed recurrent pulmonary embolism. More than a half of patients (51.9%) had multiple gene mutation and only one presented with mutations in three studied genes. It showed a significant difference in the occurrence of other thromboses in the body and significant increase in the recurrence of pulmonary embolism and residual complications in these patients. It was also observed that individuals with the 4G/5G genotype had lower neutrophil counts and neutrophil-to-lymphocyte ratio (NLR) than the 5G/5G genotype. Furthermore, it was underlined that the patients with the 5G/5G genotype were more likely to achieve complete recanalization compared to the 4G/4G genotype. Individuals carrying the 5G/5G genotype were more likely to develop a recurrence-free status as compared to those with the 4G/4G or 4G/5G genotypes. PAI-1 antigen levels in the VTE group were significantly higher than those in the HC group. Conclusion The PAI-1 4G/5G polymorphism has potential value in assessing the prognosis of patients with VTE. This study has laid the foundation for the application of PAI-1 4G/5G polymorphism in the personalized management and monitoring of patients with VTE. According to this study results PAI-1 4G/5G polymorphism could be included in laboratory testing panel of thrombophilia.

Case report: hunting the hidden: surgical treatment of chronic silent thrombus in the left ventricle in a young alcoholic patient with myocardial bridging

BackgroundA silent left ventricular thrombus is dangerous. The current standard anticoagulation therapy was ineffective in our case or similar, and the outcome was poor.Case presentationA 33-year-old man with a silent left ventricular thrombus was detected incidentally by transthoracic echocardiography. After admission, anti-coagulation with low-molecular-weight heparin therapy was carried out. The CAG revealed 70% systolic stenosis in the middle of the right coronary artery along with myocardial bridging. Unfortunately, an acute left temporal embolism emerged 5 days later, then the patient was transferred to the neurology department for further treatment. One month later, the patient underwent left ventricular thrombectomy, ventricular aneurysm resection, and coronary artery bypass grafting (CABG) and was discharged uneventfully after surgery.ConclusionsSurgical treatment should be a priority for patients with giant or hypermobile left ventricular thrombus or recurrent systemic emboli.

Recurrent paradoxical cerebral embolism caused by a thrombus entrapped in a patent foramen ovale: a case report

Introduction: A thrombus straddling the patent foramen ovale (PFO) is a very rare clinical entity. Optimal management remains unclear due to the availability of various therapeutic options; thus, an individualized approach is recommended. Case presentation: The authors describe a case presenting with recurrent cerebral embolism and a large and mobile thrombus straddled in the PFO. Historically, cardiac surgery, thrombolysis or anticoagulation were possible management options for this patient. However, there are no guidelines on what the optimal treatment is. Our patient was a poor surgical candidate because of advanced age and multiple comorbidities. Furthermore, she had a recent ischaemic stroke which was a relative contraindication to thrombolysis. After consulting the Heart Team, medical treatment alone with systemic anticoagulation was administered. Subsequent transthoracic echocardiography (TTE) after 1 week showed complete thrombus resolution. After 4 months, the PFO was successfully occluded with an Amplatzer device. The patient received rehabilitation therapy and had good functional recovery. Clinical discussion: Anticoagulant therapy alone was chosen because of high risk for surgery. Complete thrombus resolution was achieved after 1 week although the initial thrombus size was quite large. Nevertheless, this approach may not be applicable to every patient. In addition to TTE, multimodality imaging using transesophageal echocardiography and cardiac magnetic resonance is helpful to identify the mechanism of stroke, which in our case is a thrombus-straddled PFO, and to make early treatment decisions. Serial TTEs help assess the response to anticoagulation. An individualized approach should be made with a multidisciplinary Heart Team. Conclusion: Echocardiography plays an important role in the diagnosis and treatment evaluation for patients with a thrombus straddling a PFO. An individualized approach to manage the patient should be made with a multidisciplinary Heart Team.

Cardiac papillary fibroelastoma: a rare cause of ST-segment elevation myocardial infarction: a case report

Introduction and importance: Primary tumors of the heart are extremely rare occurrences. Among them, cardiac papillary fibroelastoma (CPF) is the second most common type. Although these tumors are usually benign, they can pose a risk of embolization, which may lead to severe complications like sudden death or embolization affecting the neurological, systemic, or coronary vasculature. Such complications can be life-threatening. Case presentation: In this report, the authors present the case of a 68-year-old woman who experienced ST-segment elevation myocardial infarction due to embolization from a large papillary fibroelastoma. To address the issue, the authors performed a minimally invasive surgical removal and resection of the aortic valve, followed by a histological examination to confirm the diagnosis. Clinical discussion: This case report discusses a rare occurrence of myocardial infarction caused by tumor embolization from a CPF. The patient presented with complete blockage of a coronary artery in the absence of atherosclerotic disease. Through a comprehensive workup, including transesophageal echocardiography, the CPF was identified as the source of embolization. Surgical resection of CPFs is curative, and recurrence has not been documented. Clinicians should consider CPFs in cases of coronary artery occlusion without atherosclerotic disease and employ transesophageal echocardiography for diagnosis. Prompt surgical intervention leads to an excellent prognosis and prevents recurrent embolization. Conclusion: This report emphasizes the importance of recognizing the potential complications associated with papillary fibroelastoma-induced embolization to the coronary arteries and highlights the need to mitigate the risk of such complications occurring.

Percutaneous closure of ‘complex’ multi-fenestrated atrial septal aneurysm in visceral situs inversus using a multi-device approach: a case report

Abstract Background Percutaneous closure is nowadays still deemed challenging in patent forame ovale (PFO) associated to multi-fenestrated atrial septal aneurysm (ASA). This anatomic arrangement is still considered a significant risk factor for recurrence of paradoxical embolism. Theoretically, transcatheter approach could be theoretically even more complex in the case of dextrocardia and visceral situs inversus. Case summary A 59-year-old man with history of migraine with aura and multiple cryptogenic strokes was referred for percutaneous closure of a PFO with associated ASA. He had been previously submitted to repeat attempt of percutaneous closure with not self-centering and self-centering devices that failed due to unfavorable anatomic characteristics (dextrocardia with situs viscerum inversus, huge ASA, multiple fenestrations, large PFO). Based on this “complex” anatomy, a sequential 2-step interventional approach aiming to reduce size and mobility of the atrial septal aneurysm with a suture-based approach (Noblestich™ EL, HeartStitch, Fountain Valley, CA, USA) and to close any eventual accessory fenestrations with a not self-centering occluding device was planned. At the end of the procedure, the ASA completely disappeared and no residual shunt was imaged at TEE bubble test. Discussion We describe a very rare case of symptomatic ASA-PFO in dextrocardia with situs viscerum inversus as well as an innovative approach to treat such complex anatomic setting by using the suture-based closure of a PFO to reduce size and mobility of an ASA in order to deploy dedicated not-self-centering occluding devices.

Early versus Delayed Surgery in Patients with Left-Sided Infective Endocarditis and Stroke.

Timing of surgery remains controversial in patients with infective endocarditis and stroke. Guidelines on infective endocarditis suggest delaying surgery for up to 4 weeks. However, with early heart failure due to progression of the infection or recurrent septic embolism, urgent surgery becomes imperative. Out of 688 patients who were surgically treated for left-sided infective endocarditis, 187 presented with preoperative neurological events. The date of cerebral stroke onset was documented in 147 patients. The patients were stratified according to timing of surgery: 61 in the early group (0-7 days) vs. 86 in the delayed group (>7 days). Postoperative neurological outcome was assessed by the modified Rankin Scale. Preoperative sepsis was more prevalent in patients with preoperative neurological complications (46.0% vs. 29.5%, p < 0.001). Patients with haemorrhagic stroke were operated on later (19.8% vs. 3.3%, p = 0.003). Postoperative cerebrovascular accidents were comparable between both groups (p = 0.13). Overall, we observed good neurological outcomes (p = 0.80) and a high recovery rate, with only 5% of cases showing neurological deterioration after surgery (p = 0.29). In-hospital mortality and long-term survival were not significantly different in the early and delayed surgery groups (log-rank, p = 0.22). Early valve surgery in high-risk patients with infective endocarditis and stroke can be performed safely and is not associated with worse outcomes.

Effectiveness of Transcatheter Closure of Patent Foramen Ovale in Clinical Practice.

Background Transcatheter closure of patent foramen ovale (PFO) has reduced the risk of recurrent stroke in patients with cryptogenic strokes in randomized clinical trials. Whether PFO closure in clinical practice is associated with similar benefit remains unknown. Methods and Results We identified patients with PFO and a history of ischemic stroke or transient ischemic attack who were treated with PFO closure or medical therapy in the OptumLabs database. The primary end point was recurrent ischemic stroke or systemic embolization. Secondary outcomes included mortality, all stroke, transient ischemic attack, and major bleeding. A total of 6668 propensity-matched patients were included (PFO closure n=4111; medical therapy n=2557). The incidence of stroke or systemic embolization per 100 person-years was 2.38 after PFO cohort and 2.99 with medical therapy (hazard ratio [HR], 0.85 [95% CI, 0.68-1.05], P=0.13). Mortality was lower in the PFO closure cohort (1.78 versus 2.59 per 100 person-years: HR, 0.69 [95% CI, 0.55-0.87], P=0.002). Falsification end points showed that this difference is unlikely to be completely explained by residual confounders. There were no significant differences between the groups in secondary end points including intracranial hemorrhage and major bleeding except for an increase in nonintracranial hemorrhage bleeding among patients treated with oral anticoagulation (1.42 versus 2.16 per 100 person-years: HR, 0.69 [95% CI, 0.48-0.99], P=0.043). The main end point was consistent in subanalyses including patients <60 years of age, patients with prior stroke, and those treated after the publication of the positive PFO trials in 2017. Conclusions In contemporary US practice, PFO closure is not associated with lower rates of recurrent ischemic stroke or systemic embolization compared with medical therapy. Potential reasons for this discrepancy warrant further investigation.

Intensive heart rhythm monitoring to decrease ischemic stroke and systemic embolism—the Find-AF 2 study—rationale and design

Atrial fibrillation (AF) is one of the most frequent causes of stroke. Several randomized trials have shown that prolonged monitoring increases the detection of AF, but the effect on reducing recurrent cardioembolism, ie, ischemic stroke and systemic embolism, remains unknown. We aim to evaluate whether a risk-adapted, intensified heart rhythm monitoring with consequent guideline conform treatment, which implies initiation of oral anticoagulation (OAC), leads to a reduction of recurrent cardioembolism. Find-AF 2 is a randomized, controlled, open-label parallel multicenter trial with blinded endpoint assessment. 5,200 patients ≥ 60 years of age with symptomatic ischemic stroke within the last 30 days and without known AF will be included at 52 study centers with a specialized stroke unit in Germany. Patients without AF in an additional 24-hour Holter ECG after the qualifying event will be randomized in a 1:1 fashion to either enhanced, prolonged and intensified ECG-monitoring (intervention arm) or standard of care monitoring (control arm). In the intervention arm, patients with a high risk of underlying AF will receive continuous rhythm monitoring using an implantable cardiac monitor (ICM) whereas those without high risk of underlying AF will receive repeated 7-day Holter ECGs. The duration of rhythm monitoring within the control arm is up to the discretion of the participating centers and is allowed for up to 7 days. Patients will be followed for at least 24 months. The primary efficacy endpoint is the time until recurrent ischemic stroke or systemic embolism occur. The Find-AF 2 trial aims to demonstrate that enhanced, prolonged and intensified rhythm monitoring results in a more effective prevention of recurrent ischemic stroke and systemic embolism compared to usual care.

Spontaneous calcific cerebral embolization revealing a calcified rheumatic mitral stenosis: a case report

BackgroundCerebral cardiac embolism accounts for an increasing proportion of ischemic strokes and transient ischemic attacks. Calcified cerebral emboli are rare and mostly iatrogenic secondary to heart or aorta catheterization. However, spontaneous cerebral calcified embolism in the case of calcified aortic valve is very rare and there are less than 10 case reports in the literature. And a more interesting fact is that such an event, in the context of calcified mitral valve disease, has never been reported, at least to our knowledge. We are reporting a case of spontaneous calcified cerebral embolism revealing a calcified rheumatic mitral valve stenosis.Case presentationWe report a case of a 59 year-old Moroccan patient, with a history of rheumatic fever at the age of 14 and no history of recent cardiac intervention or aortic/carotid manipulation, who was admitted to the emergency department after a transient ischemic attack. Physical examination at admission found normal blood pressure of 124/79 mmHg and heart rate of 90 bpm. A 12-lead electrocardiogram showed an atrial fibrillation, no other anomalies. Unenhanced cerebral computed tomography imaging was performed, revealing calcified material inside both middle cerebral arteries. Transthoracic echocardiography was performed, showing severe mitral leaflets calcification with a severe mitral stenosis, probably due to rheumatic heart disease. Cervical arteries Duplex was normal. A vitamin K antagonist (acenocoumarol) was prescribed, targeting an international normalized ratio of 2–3 and mitral valve replacement surgery was performed using mechanical prosthesis. Short- and long-term health, with a 1-year follow-up, were good and the patient did not experience any stroke.ConclusionSpontaneous calcified cerebral emboli secondary to mitral valve leaflet calcifications is an extremely rare condition. Replacement of the valve is the only option to prevent recurrent emboli and outcomes are still to be determined.

Elongated Styloid Process Can be Made Responsible for Recurrent Embolic Stroke Only if Eagle Syndrome is Present

With interest we read the article by Xu et al. on a 59 year-old male with recurrent episode of left hemispheric, embolic stroke [1]. Elongated styloid process (ESP) and carotid web pocket were identified as causes of recurrent stroke [1]. After resection of the ESP and resection of the carotid web, the patient became asymptomatic during a 6 months follow-up [1]. The study is excellent but has limitations that are cause of concerns and should be discussed. The main limitation of the study is that alternative causes of embolic stroke were not entirely ruled out. We should know whether there were any indications for alternative causes of embolic stroke, such as heart failure, atrial fibrillation, Takotsubo syndrome. noncompaction, endocarditis, valve abnormalities, or myocarditis. Missing in this respect are echocardiography and ultrasound of vertebral arteries. As long as all these alternative sources of embolism were not adequately ruled out, ESP and carotid web pocket cannot be made responsible for recurrent stroke with certainty. There is also no mention of inflammatory parameters, blood coagulation parameters, platelet counts, troponin values, and pro brain-natriuretic peptide (proBNP). A strong argument against the ESP as the cause of recurrent stroke is that ESP presumably existed already for a long time. No explanation is provided why it became symptomatic just at age 58 years. Where there ever any sudden neurological deficits recognised during previous years (&gt;1.5 years before)? Another argument against ESP as the cause of recurrent stroke is that the index patient did not present with typical Eagle syndrome also referred as stylohyoid syndrome, styloid syndrome, or styloid–carotid artery syndrome [2]. Eagle syndrome is clinically characterised by orofacial and cervical pain often triggered by neck movements, by dysphagia, facial palsy, slurred speech, and vertigo [2]. Eagle syndrome can be associated with ankyloting spondylitis [3], which should have been ruled out in the index patient. The diffusion weighted imaging (DWI) lesions shown in figure 1 panel A do not explain right-sided weakness of the upper limb and amaurosis. The precentral lesions are too small and not directly in the area of the cortical upper limb representation to explain limb weakness. Regarding unilateral amaurosis, we should know whether ophthalmologists ever documented occlusion of the central retinal artery. Amaurosis triggered by head flexion suggests that each time the head is flexed embolization into the left central retinal artery occurs, which is rather unlikely. Clamping of the carotid artery by head flexion is unlikely since no cerebral symptoms with head flexion were reported [1]. Another argument against amaurosis as a manifestation of ESP is that no such cases have been previously reported. Overall, the interesting study has limitations that call the results and their interpretation into question. Addressing these issues would strengthen the conclusions and could improve the status of the study. Before attributing recurrent embolic stroke to ESP and carotid web, it is crucial to adequately rule out all alternative causes of embolic stroke. Recurrent unilateral amaurosis triggered by head flexion cannot be easily explained by ESP.

P392 POST–THROMBOEMBOLIC PULMONARY HYPERTENSION: A COMPLEX CASE

Abstract Introduction Patients with post–thromboembolic pulmonary hypertension (CTEPH) achieve functional recovery after pulmonary endarterectomy (PEA). 40% of them are inoperable (1,2). Clinical case 66–year–old man admitted in 2012 to our ward for dyspnea on exertion and high echocardiographic probability of pulmonary hypertension (PI). Medical history: smoking; thalassemia trait; COPD; splenectomy at 13; diagnosis of chronic myeloproliferative syndrome. BP: 120/70 mmHg. NYHA class III. Blood tests: Hb: 9.4 g/dl; MCV: 70; HCT: 30%; PLT: 511; WBC: 14.84 (Mo 13%).NT–pro BNP:933. Autoantibodies and tests –HIV: negative. EGA in AAPaO2: 53 mmHg, PaCO2: 32 mmHg, SO2: 87%. PFR: FEV1: 68% FVC:74%, FEV1/FVC:72.DLCO:75%.6MWT:450m,Borg:0/3;Baseline SO2: 86%,final SO2 74%. On ECG: sinus r. at 64 beats/min. Echocardiogram: left sections within limits; right ventricle:DTD:30mm; RV/LV&amp;lt; 1; right atrial area: 19cm2, PAPs: 70+5 mmHg (Vel: 4.1 m/s), AcT: 90 msec. TAPSE: 16mm. Performs pulmonary CT scan with contrast medium: negative for pulmonary embolism; some 1 cm bubbles of emphysema in the subpleural area of the right middle lobe; right heart catheterization: PAD: 13mm; PAPM: 50mm; IC: 4.1l /min/m2; RVPtot:11WU;RVP:art:5.2WU;WP:11mmHg.Haematological diagnosis of thalassemia intermedia and exclusion of myeloproliferative syndrome/P lung scintigraphy is positive for multiple bilateral perfusion defects. The possibility of PEA for peripheral lesions at the referral Centre, therapy with warfarin (TAO), riociguat and bronchodilators was started., discontinued therapy with TAO. Finding of recurrence of pulmonary micro embolism on scintigraphy. At the end of the intravitreal treatments with resumption of TAO, at control catheterization evidence of PAD:5mm PAPm19mmHg;WP:9mmHg;IC: 3.4l/min/m2; RVPart:2.9 WU;NYHA:II. Discussion Not all CTEPH from thalassemia intermedia can perform PEA (3). Hypercoagulability is an important pathogenetic mechanism in the genesis of PH (4) and comorbidities have a significant role in the prognosis and response to medical therapy. COPD is the comorbidity that favors hypercoagulability, worsens pulmonary ventilation and gaseous exchanges (5). Conclusions In thalassemia intermedia with inoperable CTEPH, hypercoagulability is the condition that most influences the prognosis and efficacy of vasodilator therapy.

P391 THE DIAGNOSTIC CHALLENGE BETWEEN CHRONIC PULMONARY EMBOLISM AND PULMONARY ARTERY SARCOMA: A CASE REPORT

Abstract We report the case of a 63–year–old obese and hypertensive woman, admitted in hospital with worsening dyspnea for 2 weeks and syncope. A suspected chronic thromboembolism was diagnosed nine months before for a similar clinical picture; hematologic screening excluded thrombophilia and NOACs were prescribed. Two–dimensional transthoracic echocardiography showed enlargement of right chambers, the interventricular septum shifted to the left ventricle, showing “D” sign. Color Doppler flow imaging showed moderate regurgitation in tricuspid valve, with indirect pulmonary pressure estimation 90 mmHg. Left ventricle was normal for dimensions and function. ECG evidenced sinus tachycardia and no specific ST–T alterations. Blood exams evidenced anemia (Hb 9 mg/dl), negative neoplastic markers and absence of occult blood in feces, mildly elevated inflammatory markers, T–Troponin and D–dimer. Naso–pharyngeal swab for SARSCoV2 infection was negative. Chest computed tomography with contrast revealed a large filling defect within bilateral main pulmonary arteries. No lymph nodes or pulmonary pneumonia were detected. Lower extremity venous ultrasound was positive for right popliteal deep vein thrombosis. The global clinical picture suggested an acute pulmonary embolism recurrence, with a severe right ventricle impairment and a concomitant deep vein thrombosis. Some factors were not completely clear: chronic anemia, only mildly increased D–dimer, no specific increase of inflammatory markers. The patient was referred to Cardiac Surgery Unit of IRCCS Foundation Policlinico San Matteo in Pavia, for pulmonary endarterectomy. Unexpectedly the surgical finding was a bilateral pulmonary artery sarcoma, confirmed by histological exam. We thus clarified some uncertain clinical aspects, explainable in the context of a severe neoplastic picture. There were no immediate complications, and a chemotherapy was initiated after a period of cardio–pulmonary rehabilitation. Pulmonary artery intimal sarcoma is a very rare disease, its prevalence is about 0.001–0.003%, it can originate from the left and right pulmonary arteries and intimal layer of pulmonary arteries, forming a tumor growing in the nodular cavity or spreading along the intimal surface. PAS is often misdiagnosed as acute or chronic pulmonary thromboembolism due to its clinical presentation and radiological findings. Thus, early diagnosis is very crucial and may improve patient outcome.

Using a low-metal-density stent for thrombectomy-resistant vertebrobasilar occlusion due to thrombus migration from a thrombosed vertebral artery aneurysm: illustrative case.

Thrombosed intracranial aneurysms can lead to large vessel occlusion as a result of spontaneous thrombosis. Although mechanical thrombectomy is likely effective, recurrent thromboembolism can occur if the thrombotic source remains untreated. The authors describe a case of recurrent vertebrobasilar artery occlusion due to thrombus migration from a large thrombosed vertebral artery (VA) aneurysm that was successfully treated with mechanical thrombectomy followed by stenting. A 61-year-old male previously diagnosed with a large, thrombosed VA aneurysm presented with right hypoesthesia. Imaging on admission showed left VA occlusion and an acute ischemic lesion in the left medial medulla. His symptoms worsened, with complete right hemiparesis and tongue deviation occurring 3 hours after admission, and mechanical thrombectomy was performed to recanalize the left-dominant VA. Despite several attempts, reocclusion of the vertebrobasilar system occurred after each mechanical thrombectomy because of repeated thrombus formation in the thrombosed aneurysm. Therefore, a low-metal-density stent was deployed to prevent thrombus migration into the parent artery, which resulted in complete recanalization and rapid improvement of the symptoms. Stenting with a low-metal-density stent for recurrent embolism secondary to thrombus migration from a large thrombosed aneurysm was feasible in the acute stroke setting.

Combination of recurrent thyroid artery embolization and sorafenib treatment in the management of inoperable papillary thyroid cancer

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Minimally Invasive Extirpation of Benign Atrial Cardiac Tumors: Clinical Follow-Up and Survival.

Evidence determining the optimal treatment for cardiac tumors is rare. We report our midterm clinical outcome and patient characteristics of our series undergoing atrial tumor removal through a right lateral minithoracotomy (RLMT). From 2015 to 2021, 51 patients underwent RLMT for atrial tumor extirpation. Patients receiving concomitant atrioventricular valvular, cryoablation, and/or patent foramen ovale closure surgery were included. Follow-up was performed using standardized questionnaires (mean: 1,041 ± 666 days). Follow-up involved any tumor recurrence, clinical symptoms, and any recurrent arterial embolization. Survival analysis was successfully achieved in all patients. Successful surgical resection was achieved in all patients. Mean cardiopulmonary bypass and cross-clamping times were 75 ± 36 and 41 ± 22 min, respectively. The most common tumor location was the left atrium (n = 42, 82.4%). Mean ventilation time was 12.74 ± 17.23 h, intensive care unit stay ranged from 1 to 1.9 days (median: 1 day). Nineteen patients (37.3%) received concomitant surgery. Histopathological analysis showed 38 myxoma (74.5%), 9 papillary fibroelastoma (17.6%), and 4 thrombus (7.8%). Thirty-day mortality was observed in 1 case (2%). One patient (2%) suffered a stroke postoperatively. No patient had a relapse of cardiac tumor. Three patients (9.7%) showed arterial embolization during follow-up. Thirteen follow-up patients (25.5%) were in New York Heart Association class ≤II. Overall survival was 90.2% at 2 years. A minimally invasive approach for benign atrial tumor resection is effective, safe, and reproducible. Of the atrial tumors, 74.5% were myxoma and 82% were located in the left atrium. A low 30-day mortality rate with no manifestation of recurrent intracardiac tumor was observed.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Transjugular patent foramen ovale closure in a young patient with stroke caused by inferior vena cava thrombus: a different method with balloon anchor support to pulmonary vein.

Patent foramen ovale closure is recommended for patients who are at risk for recurrent paradoxical embolism and cryptogenic stroke. The standard technique of patent foramen ovale closure is established from the femoral vein. However, alternative methods may be necessary for patent foramen ovale closure as in every interventional procedure. A 45-year-old female patient with an intramural giant uterine myoma had a history of recurrent deep vein thrombosis and stroke. A diffuse thrombus was detected in both iliac veins associated with inferior vena cava compression of the myoma. Also, a patent foramen ovale was revealed on echocardiography as a cause of embolic events. Hysterectomy was initially planned by gynaecology, but due to the possible risk of embolisation of inferior vena cava thrombus and stroke after removal of the compressive mass during hysterectomy, initial patent foramen ovale closure and then hysterectomy was scheduled in the Gynecology-Cardiology-Cardivascular Surgery council. Patent foramen ovale closure was performed via the right jugular vein approach. But because of the tight left atrial ostium of the patent foramen ovale, the catheter could not pass to the left atrium from the right atrium. With an anchor of a 5.0 × 15 mm coronary balloon over a 0.014-inch guidewire to the pulmonary vein, we were able to reach the left atrium. The patent foramen ovale was closed successfully, and the patient underwent a hysterectomy after closure without any embolic event. The patient was asymptomatic at 6 months of control.