Recurrent Embolism Research Articles

Safety of low-dose prolonged infusion of tissue plasminogen activator therapy in patients with thromboembolic events in the intensive care unit.

Objective Thromboembolic events such as acute coronary syndrome related prosthetic heart valve thrombosis, pulmonary artery embolism and renal artery embolism are a rare condition but a major cause of morbidity and mortality. In this study we discussed low-dose thrombolytic therapy, in patients with thromboembolic events in the intensive care unit.Methods The study was performed on 12 consecutive patients [8 female; 50.3±16.0 (35-95) years] with acute thromboembolism including acute coronary syndrome related prosthetic heart valve thrombosis, acute pulmonary embolism and acute renal embolism who were treated with low-dose (25 mg) and slow infusion (6 hours) of t-PA. We evaluated mainly in-hospital safety and also effectiveness.Total treatment episodes was 1.66±0.88 (1-4) times.Results All thromboembolic events have been successfully treated with low-dose (25 mg) and slow infusion (6 hours) of t-PA. The success criteria were clinically improvement and radiologically lysis. None of the patients had ischemic stroke, intracranial hemorrhage, embolism (peripheral and recurrence of coronary artery embolism), bleeding requiring transfusion. The most frequent in-hospital complication was a gum bleeding without need for transfusion (two patients).Conclusions In our case series low-dose (25 mg) and slow infusion (6 hours) of t-PA have been performed successfully for thromboembolic events including acute coronary syndrome related prosthetic heart valve thrombosis, pulmonary embolism and renal embolism in patients with in the intensive care unit. Safety is promising and if efficacy will be proved; this method may be a valuable alternative to standard fibrinolytic regimen.

Myeloproliferative Diseases as Possible Risk Factor for Development of Chronic Thromboembolic Pulmonary Hypertension-A Genetic Study.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease which is often caused by recurrent emboli. These are also frequently found in patients with myeloproliferative diseases. While myeloproliferative diseases can be caused by gene defects, the genetic predisposition to CTEPH is largely unexplored. Therefore, the objective of this study was to analyse these genes and further genes involved in pulmonary hypertension in CTEPH patients. A systematic screening was conducted for pathogenic variants using a gene panel based on next generation sequencing. CTEPH was diagnosed according to current guidelines. In this study, out of 40 CTEPH patients 4 (10%) carried pathogenic variants. One patient had a nonsense variant (c.2071A>T p.Lys691*) in the BMPR2 gene and three further patients carried the same pathogenic variant (missense variant, c.1849G>T p.Val617Phe) in the Janus kinase 2 (JAK2) gene. The latter led to a myeloproliferative disease in each patient. The prevalence of this JAK2 variant was significantly higher than expected (p < 0.0001). CTEPH patients may have a genetic predisposition more often than previously thought. The predisposition for myeloproliferative diseases could be an additional risk factor for CTEPH development. Thus, clinical screening for myeloproliferative diseases and genetic testing may be considered also for CTEPH patients.

A rare case of recurrent paradoxical embolisation

The reported incidence of paradoxical embolisms is relatively low, forming less than 2% of systemic arterial embolisation with patent foramen ovale (PFO) as the identified cause in more than 90% of the cases. We present an interesting case with recurrent paradoxical embolisation, despite taking

Variable predictors of acute pulmonary embolism recurrence with duration of follow-up.

BackgroundAcute pulmonary embolism (PE) is a critical disease and often leads to a high mortality and morbidity. Several studies have identified predictors of PE recurrence, but whether these predictors have prognostic value and how they vary during varied follow-up periods remain unclear.MethodsWe retrospectively assessed the occurrence of recurrent PE and the survival time of patients with a diagnosis of acute PE at Shanghai Pulmonary Hospital from May 2007 to May 2018. Potential predictors of recurrent PE were evaluated at different points (1, 3, 6, 12, 24, 60 and 120-month) during a long-term follow-up for each patient. Patients were stratified into two groups by gender to analyze the impact of sex in period-guided prognostic prediction. Receiver operating characteristic curve analysis, survival analysis and multivariate Cox proportional hazards analysis were implemented as statistical analysis methods.ResultsIn total, 597 acute PE patients were included, of whom 62 reported a PE recurrence. Male patients tend to have a lower risk of PE recurrence than female patients during 3- to 60-month follow-up period but have a higher risk of PE recurrence than female patients during 120-month follow-up period. The independent predictors of recurrence-free survival varied among different follow-up periods: In all patients, diabetes was an independent predictor only within 30 days follow-up period and female was considered as an independent predictor during 3- to 120-month follow-up period. Among male patients, hyperlipidemia and Log D-dimer (cut-off value =3.436) was observed as a predictor of recurrent PE within 6-month and over 12-month follow-up respectively. However, there is no unified independent prognostic indicator for female patients identified.ConclusionsIn the early stage of follow-up, male PE patients have better prognosis, but with the extension of follow-up, female PE patients have better prognosis. The independent predictors of recurrence-free survival vary in different follow-up periods in PE patients when stratified based on gender and associated medical conditions.

Abstract TP33: Early Recurrent Stroke and Systemic Embolism After Mechanical Thrombectomy: The Effect of Post-Treatment Intracranial Hemorrhage

Background and purpose: There are risks of recurrent stroke and systemic embolism during the early period after mechanical thrombectomy (MT) especially in patients with hemorrhagic transformation because of delayed initiation of anticoagulants. We assessed the rate of early recurrent embolism (ERE) after MT and the effect of intracranial hemorrhage on ERE. Methods: Patients who underwent MT for acute ischemic stroke in our institution between January 2014 and July 2019 were retrospectively reviewed. ERE was defined as symptomatic recurrent stroke and systemic embolism within 14 days after MT. A multivariable logistic regression model with prespecified covariates including anticoagulants within 48 hours after MT was constructed to determine the association between ERE and parenchymal hemorrhage (PH) within 36 hours (SITS-MOST definition). Adjustment for differences in baseline characteristics between patients with and without PH was performed using the inverse probability of treatment weighting (IPTW). Results: A total of 300 patients (mean age, 75.4 years; female patients, 49%; median baseline National Institutes of Health Stroke Scale score, 18 [IQR, 12-25]) were included. ERE was observed in 12 of 300 patients (8 strokes and 4 systemic embolisms; 4.0%; 95% confidence interval [CI], 2.3 to 9.3). The median time from MT to ERE was 6.5 days (IQR, 3-8) and no ERE occurred before PH. Patients with PH were not likely to be initiated anticoagulants within 48 hours after MT (41 % vs. 77%, p &lt; 0.01). In multivariable analysis, PH was significantly associated with an increased risk of ERE (unweighted odds ratio, 5.61; 95% CI, 1.25 to 25.27, p = 0.025). After weighting for IPTW, PH remained an independent predictor of ERE (weighted odds ratio 6.20, 95% CI, 1.05 to 36.57, p = 0.044). Conclusions: ERE occurred in about 4% of patients after the MT. Our results reveal a dilemma that intracranial hemorrhage after reperfusion therapy may increase the risk of recurrent embolism.

Upper extremity deep vein thrombosis treated with direct oral anticoagulants: a multi-center real world experience.

Upper-extremity deep vein thrombosis (UEDVT) accounts for about 5-10% of all cases of deep vein thrombosis (DVT). It is often associated with cancer and/or presence of a central venous catheter (CVC), but it may also occur in the absence of these favoring conditions. The safety and efficacy of using direct oral anticoagulants (DOACs) in subjects with UEDVT has not been systematically evaluated and the only data available in the literature derive from anecdotal evidence, analysis of registries, and small single-centre studies. In addition, a specific analysis of UEDVT not associated with cancer and/or CVC has never been made. In this study, we specifically focused on patients with no cancer and without a CVC who were diagnosed with a first episode of UEDVT and were treated with a DOAC. We studied 61 patients, treated in six Italian centres between January 2014 and December 2018. Treatment lasted at least 3months in all patients. In terms of efficacy, no recurrence of thrombosis or pulmonary embolism were recorded, while Doppler ultrasonography, performed after at least three months of treatment, documented in all cases either partial or complete recanalization of obstructed veins. In terms of safety, no cases of major bleedings were recorded. This is the only series available in the literature of patients treated with DOACs for UEDVT not associated with cancer and/or CVC. This small multicenter real world experience supports the concept that DOACs might be safe and effective for treating UEDTV. Further studies are required to better understand the role of DOACs in these patients.

Long-term outcome of resuming anticoagulation after anticoagulation-associated intracerebral hemorrhage.

IntroductionThe risk and benefit of restarting oral anticoagulation (OAC) therapy among patients with atrial fibrillation or flutter (AF) and an episode of anticoagulation-associated intracerebral hemorrhage (ICH) remain unclear. Whether or not to resume OAC after an OAC-associated ICH will remain an unanswered clinical question until we have sufficient data through randomized clinical trials. Here, we analyzed the long-term outcome of patients with AF who did or did not resume OAC after an OAC-associated ICH.Patients and methodsWe studied consecutive patients with AF who were discharged from our institution after an OAC-associated ICH event between 2010 and 2017. Baseline characteristics of patients, past medical history, and history or OAC use were recorded. Outcome measures in our study included recurrent ICH, ischemic stroke or systemic emboli, and death.ResultsOut of 115 patients with AF and OAC-associated ICH, 93 patients (mean age 76.2 ± 10.3 years [44–91 years old], 54.3% men) were included in this study. Thirty-eight (40.9%) patients resumed OAC after the episode of OAC-associated ICH. More than 70% of patients had resumed OAC within two months of ICH (mean delay 56.0 ± 52.5 days). There was no significant difference between the group who resumed OAC and the group who did not in terms of mean follow-up duration (1.9 vs. 2.4 years), the type of initial ICH, as well as history of hypertension, diabetes, previous ischemic stroke, congestive heart failure, coronary artery disease, and tobacco use. There was no significant difference between the two groups considering the incidence rate of recurrent ICH (relative risk 2.9; 95% CI, 0.3–30.8). There was also no significant difference between the two groups regarding the incidence rate of ischemic stroke or systemic emboli (relative risk 0.9; 95% CI, 0.3–2.7). There was no significate difference between patients who did and did not resume OAC was 96 and 121 per 1000 patient-years, respectively (relative risk 0.8; 95% CI, 0.3–1.9).ConclusionsWe did not observe any significant difference between the group of patients who resumed OAC and the patients who did not in terms of recurrent ICH, ischemic stroke or systemic emboli, and death. However, there was a tendency toward a higher long-term risk of recurrent ICH among patients who resumed OAC.

P719 Complex cyanotic congenital heart disease and its complications- it is never too late to treat

Abstract Noncardiac complications significantly contribute to the morbidity and mortality of adults with congenital heart disease (CHD), mainly because life expectancy and quality of life for those born with CHD have greatly improved in the last decades. Double-outlet right ventricle (DORV) with a subaortic ventricular septal defect (VSD) associated with subpulmonary stenosis is a complex cyanotic congenital heart disease from the spectrum of tetralogy of Fallot. We present the case of a young male who was diagnosed at the age of 18 with DORV with subaortic VSD (Figure A), subpulmonary stenosis (Figure C) and mitral valve malformation (anterior leaflet cleft (Figure B) and both leaflets prolapse) with secondary moderate mitral regurgitation (MR), associated with major aortopulmonary collaterals, without pulmonary hypertension. There was no surgical correction at that moment. At the age of 26 he presented with recurrent hemoptysis and embolisation of bronchial arteries was performed. In the same year, a cerebral MRI showed signs of multiple infratentorial and supratentorial ischemic strokes. One year later, he was diagnosed with brain abscess and otomastoiditis that were surgically managed; multiple microorganisms were isolated from the two sources (M. morganii, K. pneumoniae, P . aeruginosa) and the patient received prolonged antibiotic therapy. Two months later he presented with clinical, biological and echocardiographic signs of infective endocarditis (IE) and blood cultures confirmed the diagnosis of Candida albicans associated mitral valve IE (Figure D, E, F, G). Antifungal therapy was administered for one month, with the complete disappearance of the vegetation, but worsening of the mitral regurgitation and moderate left ventricular systolic dysfunction. Thus, the patient had a clear indication for mitral valve replacement together with complete repair of the cardiac malformation that seemed still feasible as the pulmonary arteries were well developed, there was no pulmonary vascular disease and the systolic function of the RV was normal. Correction of CHD was performed in March 2019 consisting of repair of the DORV (Figure H), mitral valve replacement (33 mm bileaflet mechanical valve) (Figure I), tricuspid valve repair with RVOT remodelling. Postoperative, the patient clinical status improved significantly and transthoracic echocardiography revealed a mild residual subpulmonary stenosis (Figure J) and normally functioning mitral prosthesis. There are frequent, various complications in the natural history of congenital heart diseases, especially unrepaired. This case illustrates how vicious the circle of complications can get in a case of unrepaired cyanotic cardiac malformation and the difficulty of breaking this circle. The correction of CHD is the best prevention method and should be performed whenever it is feasible, even at an adult age. Abstract P719 Figure.

354 Incidence and Implication of Persistently Positive Agitated Saline Contrast Studies (ASCS) at 6 Months Post-transcatheter Patent Foramen Ovale (PFO) Closure - Is the Juice Worth the Squeeze?

Transcatheter PFO closure following cryptogenic stroke is performed to prevent recurrent paradoxical embolisation. ASCS during follow-up transthoracic echocardiography (TTE) is routinely undertaken post-procedure to assess for residual right-to-left shunting (RLS). A positive “bubble” study may indicate incomplete device closure/endothelization, or undiagnosed co-existent shunt, however the clinical relevance remains undefined. To determine the incidence of positive ASCS at 6 months post-PFO device closure following cryptogenic stroke and its predictive value for recurrent thromboembolic events. A retrospective review of all TTEs performed at 6 months post-transcatheter PFO closure with an Amplatzer device was undertaken. In patients with a positive ASCS, medical records were then audited for any documented cerebral embolic related re-presentations. 86 patients (49% females; mean age 42±9 yrs.) were included. 30 (35%) cases were positive ASCS, of which 14 (47%) were early (Bubbles in the left heart within <5 cardiac cycles) suggestive of atrial level shunting and 16 (53%) were late (>5 cardiac cycles) implying concomitant extra-cardiac shunting. 2 patients had evidence of peri-closure device shunting on colour flow mapping without the need for ASCS. Over a median follow-up of 3.3 yrs., only 1 patient with any evidence of a residual inter-atrial or intra-pulmonary connection suffered a recurrent stroke. A positive ASCS 6-months after PFO device closure, indicative of persistent RLS, is relatively common. This in isolation does not appear to translate into significant repeat thromboembolic complications. Larger prospective studies with serial ASCS and longer-term follow-up may be useful for further validation.

388 Persistent Left Superior Vena Cava With Unusual Drainage

Persistent left superior vena cava (PLSVC) can lead to thromboembolic phenomena including transient ischaemic attacks and stroke. This case report signifies the importance of its identification through simple investigations like echocardiography. The management of this condition described in literature is predominantly surgical. Treatment of this condition with anticoagulation, as described in our paper is a novel approach in managing this condition. A 64-year-old man with a background of dyslipidemia and hypertension presented with symptoms of aphasia and confusion. He was diagnosed with a bi-hemispheric stroke on MRI brain. A transoesophageal echocardiogram was performed as a part of the stroke work up. A bolus of agitated gelofusine administered via a left-sided cannula showed immediate contrast opacification of the left atrium before the right atrium, indicative of a venous to systemic shunt. When agitated gelofusine was injected via the right arm, normal contrast filling was demonstrated in the right atrium first. A cardiac CT confirmed the presence of a PLSVC draining into the left side of the heart. He was commenced on apixaban as secondary prevention for recurrent paradoxical embolisation and remains symptom free one year after initial presentation. In a setting of cryptogenic stroke, a venous-to-arterial shunt caused by a PLSVC should be considered as a potential source of embolus. Echocardiography with contrast injections from both arms should be carried out to assess possible anomalous thoracic venous drainage. Making the diagnosis of venous-to-systemic shunt would help formulate appropriate management to prevent recurrence of embolic phenomena.

Multiple embolism of arterial vessels of the systemic circulation: classification, clinical manifestations, and outcomes

Embologenic arterial obstruction remains an extremely important problem of modern medicine. Emboli may affect virtually all arterial vessels of the greater circulation and in some cases arterial emboli may be multiple. The purpose of the present study was to work out a classification of multiple arterial emboli. Analysing the clinical material including over 30 years a total of 1804 patients with embolism of the aorta and major arteries of the limbs made it possible to define the range of the terms used and to submit for discussion a classification describing a situation where emboli affect simultaneously several arteries or occur repeatedly. Both cases involve several emboli migrating from the primary source into the arterial bed, therefore we suggest that all these emboli be called multiple. Simultaneous multiple emboli were classified as combined, multifocal, and layered, with repeated emboli classified as preceding, recurrent, early and remote. Simultaneous emboli were observed in 91 (5%) patients, of these, in 22 - combined, in 49 - multifocal, in 19 - layered, and in 1 case - combined and multifocal. Repeated emboli were revealed at various terms and encountered virtually in each third patient. Overall mortality amongst the patients with embolism of the aorta and arteries of the limbs over 30 years amounted to 13%, having over the last decade decreased to 7.6%. Multiple arterial emboli significantly influenced the outcomes of treatment, with the mortality rate in combined emboli increasing virtually to 50% and that in multifocal and layered emboli exceeding 20% (p<0.05). Early recurrent emboli in the postoperative period were observed in 6.8% of patients, significantly deteriorating the prognosis (mortality - 49.2%). In the remote period, 22.4% of the patients were operated on for recurrent embolism of arteries of the extremities, with more than 25% of the patients having experienced emboli of cerebral or visceral arteries. Recurrent thromboembolic complications played a significant role in the thanatogenesis in each 4th patient.

Exercise Capacity and Ventilatory Efficiency in Patients With Pulmonary Embolism After Short Duration of Anticoagulation Therapy

BackgroundAlthough anticoagulation therapy can reduce the risk for pulmonary embolism (PE) recurrence, symptoms such as exertional dyspnea or pain can persist for several months to years. Therefore, we aimed to assess the improvement of ventilatory efficiency and exercise capacity during cardiopulmonary exercise test in PE patients after short duration of anticoagulant therapy. Materials and MethodsPulmonary function testing, arterial blood gas analysis and cardiopulmonary exercise test were performed in 30 PE patients after anticoagulant therapy of 4 weeks (early phase) and after 6 months (late phase). In addition, another 30 healthy volunteers underwent the same tests. ResultsPercentage of forced vital capacity (FVC %pred) improvement was evident in the PE group (P < 0.01) after 6 months of treatment. Peak Load, peak Load %pred, peak oxygen uptake (V∘O2), peak V∘O2%pred increased significantly after treatment for 6 months (P < 0.01), while lowest minute ventilation in relation to carbon dioxide production (V∘E / V∘CO2) and lowest V∘E / V∘CO2 %pred decreased significantly (P = 0.001). In PE group, the increment of peak V∘O2 %pred from 4 weeks to 6 months correlated with the decrease of lowest V∘E / V∘CO2 %pred (r = 0.639, P < 0.001) but not the increment of FVC %pred (r = 0.058, P = 0.769). ConclusionsExercise capacity improved significantly and there was a gradual improvement in ventilatory efficiency after 6 months of anticoagulation therapy.

The effect of obstructive sleep apnea and CPAP therapy on the pulmonary embolism recurrence

The effect of obstructive sleep apnea and CPAP therapy on the pulmonary embolism recurrence

Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration.

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

A hidden aortic rupture heralded by recurrent brain and retinal embolism

Central MessageAn unrecognized contained aortic rupture may be responsible for repeated embolism and may be detected by means of transthoracic, transesophageal 2-dimensional echocardiography and computed tomography.See Commentary on page 17. An unrecognized contained aortic rupture may be responsible for repeated embolism and may be detected by means of transthoracic, transesophageal 2-dimensional echocardiography and computed tomography. See Commentary on page 17. Atherosclerotic changes in the aortic wall of major arterial vessels represent an important risk factor of systemic embolism. Necropsy studies have demonstrated that complicated aortic plaques are variably associated with ischemic cerebral lesion that may be clinically silent.1Khatibzadeh M. Mitusch R. Stierle U. Gromoll B. Sheikhzadeh A. Aortic atherosclerotic, plaques as a source of systemic embolism.J Am Coll Cardiol. 1996; 27: 664-669Crossref PubMed Scopus (129) Google Scholar In the patient described here, the source of systemic embolism was identified in a previously undiagnosed calcific pseudoaneurysm of the noncoronary sinus. A 65-year-old man experienced recurrent strokes with areas of brain and retinal ischemia (Figure 1, A and B). After hospitalization, continuous monitoring excluded episodes of atrial fibrillation. Transthoracic and transesophageal 2-dimensional echocardiography (Figure 1, C) showed moderate aortic regurgitation and the presence of a 7 × 5 cm saccular aneurysm of the noncoronary sinus that was confirmed by a computed tomography, which also showed gross calcification of the wall (Figure 1, D). At surgery, firm adhesions between the aortic root and the right atrium raised the suspicion of a pseudoaneurysm due to undiagnosed contained rupture (Figure 1, E); fragile calcific deposits (Figure 1, F) were considered the source of embolization. Repair of the pseudoaneurysm was obtained by replacement of the noncoronary sinus using a polyethylene terephthalate patch. The patient recovered uneventfully with no further embolic episodes at 3-month follow-up.

Current AATS guidelines on surgical treatment of infective endocarditis.

The 2016 American Association for Thoracic Surgery (AATS) guidelines for surgical treatment of infective endocarditis (IE) are question based and address questions of specific relevance to cardiac surgeons. Clinical scenarios in IE are often complex, requiring prompt diagnosis, early institution of antibiotics, and decision-making related to complications, including risk of embolism and timing of surgery when indicated. The importance of an early, multispecialty team approach to patients with IE is emphasized. Management issues are divided into groups of questions related to indications for and timing of surgery, pre-surgical work-up, preoperative antibiotic treatment, surgical risk assessment, intraoperative management, surgical management, surveillance, and follow up. Standard indications for surgery are severe heart failure, severe valve dysfunction, prosthetic valve infection, invasion beyond the valve leaflets, recurrent systemic embolization, large mobile vegetations, or persistent sepsis despite adequate antibiotic therapy for more than 5-7 days. The guidelines emphasize that once an indication for surgery is established, the operation should be performed as soon as possible. Timing of surgery in patients with strokes and neurologic deficits require close collaboration with neurological services. In surgery infected and necrotic tissue and foreign material is radically debrided and removed. Valve repair is performed whenever possible, particularly for the mitral and tricuspid valves. When simple valve replacement is required, choice of valve-mechanical or tissue prosthesis-should be based on normal criteria for valve replacement. For patients with invasive disease and destruction, reconstruction should depend on the involved valve, severity of destruction, and available options for cardiac reconstruction. For the aortic valve, use of allograft is still favored.

Efficacy comparison between operation and non-operation treatment for hip fractures patients complicated with pulmonary embolism

Objective To investigate efficacy of operation and non-operation treatment for hip fractures patients complicated with pulmonary embolism. Methods A retrospective case control study was conducted to analyze the clinical data of 18 hip fracture patients complicated with pulmonary embolism admitted to Dongyang People's Hospital from May 2017 to January 2019. There were 11 males and seven females, aged 59 to 96 years[(80.0±9.3)years]. There were 10 patients with intertrochanteric fractures, one with femoral subtrochanteric fracture and seven with femoral neck fractures. After diagnosis of pulmonary embolism, the patients were given anticoagulant therapy with low molecular weight heparin for at least one week. The re-examination showed that pulmonary embolism absorption improved and D-dimer did not increase. Eleven patients chose surgical treatment (operation group) with intramedullary nail internal fixation or artificial hip replacement. Seven patients chose non-surgical treatment (non-operation group) with skin traction. The Harris score of hip function was compared between the two groups. Visual analogue scale (VAS) was used to evaluate hip joint pain. At the last follow-up, fracture healing, prognosis of pulmonary embolism and mortality within 3 months were recorded. Results All the patients were followed up for 3-22 months [(11.2±6.0)months]. At last follow-up, the Harris score was (92.1±2.2)points in the operation group and (28.8±18.8)points in the non-operation group (P<0.01); the VAS was 0 point (0-1 point) in the operation group and 3 points (1-3 points) in the non-operation group (P<0.01). At the last follow-up in the operation group, five patients obtained fracture healing after internal fixation, and among the six patients receiving artificial joint replacement, five patients recovered well except for one deceased patient. At the last follow-up, pulmonary embolism was absorbed and no recurrence of pulmonary embolism was found. None of the patients died within 3 months in operation group, while 14% of the patients (1/7) in the non-operation group died within 3 months. Conclusions For hip fracture patients complicated with pulmonary embolism, compared with non-operation treatment, operation treatment is more beneficial to restore hip function and relieve pain, with lower mortality rate within 3 months. Operation treatment is feasible for patients who showed improved absorption of pulmonary embolism and no secondary increase of D-dimer after one to two weeks of full anticoagulation treatment before operation. Key words: Hip fractures; Pulmonary embolism; Operation

SIMULTANEOUS MULTIFOCAL PARADOXICAL EMBOLISM IN AN ELDERLY PATIENT WITH PATENT FORAMEN OVALE: A CASE REPORT

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Paradoxical embolism (PDE) refers to an embolus of venous origin which is carried directly into the arterial circulation, or vice versa through an arteriovenous shunt such as a patent foramen ovale (PFO). PFO is usually asymptomatic; however, it may play a role in the development of a cryptogenic stroke (CS). About one-third of the cryptogenic strokes may be associated with a PFO. PDE has a diverse clinical presentation and the nature and complications of this pathology can be potentially life-threatening. CASE PRESENTATION: A 68-year-old female with a medical history of hypertension was admitted with complaints of acute visual disturbances, manifested as partial hemianopia without headache. On physical examination, she had no neurological dysfunction. Heart sounds were normal. A computed tomography (CT) scan of the brain showed a 7mm hyperdensity in the left cerebellar area. Tissue plasminogen activator was not given due to uncertainty about the time of onset of the symptoms. The patient was started on aspirin and atorvastatin. The next day, the patient had a sudden onset of hypoxia, with an oxygen saturation of 80%, as well as a left-sided facial droop and left-sided motor weakness. D-dimers were high, at 17,900 μg/ L (NL <500, ng/mL). CT angiography (CTA) of chest revealed a saddle pulmonary embolus. Agitated saline contrast exam showed significant right to left shunting across the interatrial septum, which was mobile, but appeared to be structurally intact, with only a small PFO. Subacute infarcts were seen in the right occipital-parietal area posteriorly on CT brain. She was anticoagulated with intravenous unfractionated heparin and was subsequently transitioned to argatroban. While recovering, the patient developed an acute abdomen. CT angiography revealed a nearly occlusive thrombus in the superior mesenteric artery that required embolectomy and small bowel resection. After recovery from bowel surgery, the patient underwent a planned percutaneous closure of PFO. The PFO was closed with a #28 Amplatzer septal occluder device. DISCUSSION: Simultaneous multifocal systemic embolization across a PFO is not a common occurrence. However, when multiple sites of systemic embolization occur, paradoxical embolization across a PFO should be strongly suspected. Evaluation of the interatrial septum with transesophageal echocardiography can identify several high risk features for recurrent paradoxical embolism CONCLUSIONS: Closure of PFO should be employed as a long term solution to prevent recurrence of stroke and other forms of paradoxical systemic embolization in selected patients with high risk features of the interatrial septum. Reference #1: Rakhit RD (November 2003). "Case 2: Patent foramen ovale (PFO) and paradoxical embolism". Heart. 89 (11): 1362. https://doi.org/10.1136/heart.89.11.1362. PMC 1767929. PMID 18069145. DISCLOSURES: No relevant relationships by Malik Ahmad, source=Web Response No relevant relationships by Taha Ahmed, source=Web Response No relevant relationships by Joanna Ghobrial, source=Web Response No relevant relationships by HASSAN MEHMOOD LAK, source=Web Response No relevant relationships by Anjli Maroo, source=Web Response

P3710Long term follow-up in a real-world study cohort after patent foramen ovale closure

Abstract Background Patent foramen ovale (PFO) closure is the treatment of choice after cryptogenic stroke according recent evidence. The indication is based on results of several randomized controlled trials; however, the results of these trials may not be extrapolated to a real-world clinical setting. Therefore, the aim of the present study was to evaluate long-term outcome regarding recurrent stroke, migraine, and/or peripheral embolism in patients after PFO closure. Methods We retrospectively analyzed outcomes of consecutive patients undergoing PFO closure from 2011 to 2018 at two interventional sites with respect to periprocedural events occurring during hospitalization and long-term follow-up. Follow-up data were collected from outpatient visits or telephone interviews. Results The analysis included 214 consecutive patients (mean age 52 years; 58% male). The follow-up rate was 96% and the mean follow-up time was 38 (SD 22) months. The index vascular event leading to PFO closure was stroke (n=190; 89%), including patients with repetitive stroke (n=36), embolic myocardial infarction (n=21), and migraine (n=3). One quarter (24.6%) of the population studied had an atrial septal aneurysm (&gt;15 mm). Procedural success was achieved in 98%. There were no procedure-related strokes or deaths. Periprocedural complications occurred in 16 patients (7%): two cases of pericardial tamponade, seven complications at the access site mainly caused by bleeding, two cases of transient atrial fibrillation, and five other complications. The Amplatz Septal Occluder™ was used in two thirds (64.5%) of the cases and the Gore Cardioform™ device in one third (28.6%). Four (2%) patients died during follow-up. None of these patients experienced a recurrent stroke. Ten (5%) other patients experienced a recurrent stroke. Patients with recurrent stroke events were older than patients without recurrent stroke (mean 62.6 [SD 8.8] years vs. mean 52.2 [SD 13.8] years; p=0.015) and had a higher rate of preexisting cerebrovascular occlusive disease (5 [50%] vs. 10 [6%]; p&lt;0.0001). There was no difference in risk for recurrent stroke between patients with one prior stroke and more than one stroke before PFO closure (p=0.71). Atrial fibrillation occurred in 6.6% of the patients during follow-up, but only one of these patients had recurrent stroke. No other anatomic and vascular risk factors or antithrombotic treatments were identified as being predictive of embolic events after closure. Conclusion In this real-world PFO closure cohort the recurrent stroke rate is low, although it is higher than reported in the recent randomized controlled trials. Recurrent strokes after PFO closure may reflect additional comorbid risk factors such as age or cerebrovascular occlusive disease that are unrelated to the potential for paradoxical embolism.

3311A new rat model of chronic thromboembolic pulmonary hypertension induced by repeated intravenous administration of biodegradable alginate microspheres

Abstract Introduction Chronic thromboembolic pulmonary hypertension (CTEPH) is life-threatening complication of pulmonary embolism (PE) with insufficiently understood mechanisms. Several rodent CTEPH models based on i.v. administration of non-biodegradable microparticles have been validated for preclinical studies. Major limitation of these models is the lack of partial dissolution of emboli following their entrapment in the lung vasculature. Purpose The study was aimed at development and validation of rat CTEPH model based on recurrent embolization of (sub)segmental pulmonary artery branches with biodegradable microspheres. Methods Male Wistar rats were used for the experiments. Pulmonary vasculature was embolized either with sodium alginate microspheres (MS) or with autologous blood clots (AT). The animals were randomized into the following groups: i) controls: saline at a volume of 50 μL was injected 4 times with 8-day interval into the tail vein; the same regimen was used in two next groups; ii) AT; iii) MS4; iv) MS8: MS were administered 8 times with 4-day interval. Histological examination of the lungs was performed after 2 and 6 weeks after the last injection. 6 weeks after the last injection the following analyses were performed: treadmill test, transthoracic echocardiography (TTE), right ventricular catheterization with measurement of right ventricular systolic pressure (RVSP), determination of serum endothelin-1 level. Results The survival rate in the MS8 group was 50%. In the other groups, there were no animal deaths. Multiple emboli were found in the lumen of (sub)segmental pulmonary artery branches 2 weeks after the last injection in MS4 and MS8 groups. Increased diameter and thickening of the bronchial arterial wall were also registered. After 6 weeks, the index of hypertrophy of vessel wall in MS4 and MS8 groups was significantly higher than in controls (p=0.041 and p=0.006, respectively) (Fig. 1). No sign of vascular remodeling was identified in the branches of the pulmonary artery in the AT group. Exercise tolerance was significantly reduced in both MS4 and MS8 groups compared with the controls (p=0.025 and p=0.008, respectively). There were no significant differences in exercise tolerance between the AT and control groups. TTE data indicate a significant increase in the diameter of the pulmonary trunk and the right ventricular outflow tract in the MS8 group compared with controls and AT (p&lt;0.05). Significant increase in RVSP as well as in endothelin-1 level versus controls was found only in the MS8 group. Figure 1. Histological changes in the branches of the pulmonary artery 6 weeks after the last injection of emboli. Conclusion Recurrent (×8) intravenous administration of MS in rats resulted in CTEPH development characterized by specific lung vasculature remodelling, reduced exercise tolerance, and persistent rise in RVSP. The model developed can be used for preclinical testing of promising drug candidates.