Serpentine thrombus in the heart: a rare case of trapped thrombus in patent foramen ovale

A 77-year-old Caucasian woman with recent abdominal surgery was diagnosed with multiple paradoxical systemic emboli in the mesenteric and renal circulation. Diagnosis was made by direct visualisation of a serpentine thrombus traversing both atria through patent foramen ovale (PFO) by transesophageal echocardiogram (TEE). Concomitantly, the patient was found to have deep venous thrombosis and pulmonary embolism. A decision was made to pursue cardiothoracic surgery preceded by inferior vena cava filter placement. She was started on intravenous anticoagulation. Repeat TEE was negative for thrombus and the patient did not present any new clinical signs of embolisation by this time. Consequently, the treatment plan was modified and the patient received oral systemic anticoagulation followed by PFO closure with the use of St. Jude Amplatzer Cribriform septal occluder device. During the outpatient follow-up the patient was asymptomatic and there was no significant flow through the device on transthoracic echocardiogram.

Trends in Vena Cava Filter Placement: An Analysis of Nationwide Inpatient Sample Database Over an 11 Year Period

OBJECTIVES

There have been increasing concerns regarding inappropriate usage of vena caval filters. Our study was done to analyze the current trends in vena caval filter placement.

METHODS

This study used the data from Nationwide Inpatient Sample database for the years 2002- 2012 to identify patients with vena caval filter placement. Trends in both therapeutic and prophylactic vena caval filter use over the eleven years' period were analyzed. Multiple simple logistic regression model was used to assess trends.

RESULTS

The overall incidence of vena caval filter placement increased from 2002 to 2012. The odds of vena caval filter placement in 2012 were 1.340 (95% CI: 1.236, 1.453) times the odds of vena caval filter placement in 2002. However, a downward trend was observed after the year 2010. The odds of vena caval filter placement in 2012 were 0.854 (95% CI: 0.801, 0.911) times the odds in 2010. Similar trends were seen in both therapeutic and prophylactic placements. The proportion of prophylactic vena caval filter placements with indications of morbid obesity (P<0.0001), head injury (P=0.0007), surgery of the eye, brain, spine or other major surgery (P<0.0001) hemorrhage/bleeding (P=0.0046) significantly increased in 2012 when compared to 2002.

CONCLUSION

Vena caval filter placement rates have increased significantly from 2002 to 2012 for both prophylactic and therapeutic indications. However, there seems to be downward trend when comparing 2012 to 2010. Measures such as physician education and hospital audits can be done to further bring down inappropriate vena caval filter placements.

Association Between Hypothyroidism and Takotsubo Cardiomyopathy: Analysis of Nationwide Inpatient Sample Database

BACKGROUND

Takotsubo Cardiomyopathy (TC), also called transient left ventricular (LV) ballooning syndrome, resembles myocardial infarction and is characterized by LV dysfunction in the absence of coronary artery disease. Hypothesis described for TC has been an intense social stressor, pheochromocytoma, thyrotoxicosis among others. We performed this study to analyze the association of hypothyroidism with TC.

METHODS

We queried the Nationwide Inpatient Sample which represents 20% of all the United States hospital data for our study. We identified TC and hypothyroidism through their respective ICD9. Codes for years 2006-2012. SAS 9.4 was used to perform a chi-square analysis to find any statistical significance and p < 0.05 used to determine statistical significance. Significant differences were identified using odds ratio (OR) estimates.

RESULTS

A total of 19,713 cases with TC were identified of which 17,340 (87.96%) were females and 2,373 (12.04%) were males. 3,272 patients with TC had diagnosis of hypothyroidism. There is statistically significant evidence of an association between TC and hypothyroidism (OR 2.21 (95% CI: 2.11- 2.31); p<0.0001). There is evidence of increased statistical significance of females having TC 5.24 (95% CI: 4.96-5.53; (p<0.0001)) compared to males, with an increased statistically significance of females with hypothyroidism having TC, OR 6.65 (95% CI: 5.57-7.93; p< 0.001) compared to males.

CONCLUSION

There is an increased association of hypothyroidism, especially hypothyroidism for females with TC.

Rare case of massive bilateral chylothorax

We present a case of a 48-year-old woman who was referred from an outside hospital. There, she had initially underwent hysterectomy and left salpingo-oophorectomy for tubo-ovarian abscess. She later developed a colovaginal fistula and perforation of sigmoid colon and underwent Hartmann's procedure along with drainage of a left subphrenic abscess. Subsequently, she had to be intubated for acute respiratory failure and was transferred to our hospital. At our hospital, she was found to have massive bilateral pleural effusions. Bilateral small-bore chest tubes were inserted that drained milky fluid. Pleural fluid analysis was consistent with bilateral chylothorax. Thereafter, patient's respiratory status improved and she was extubated. The mechanism of chylothorax was thought be either secondary to the multiple abdominal procedures or alternatively as a complication of the right subclavian catheter that was placed at the outside hospital. Her chest tubes were removed eventually, and she had a slow but definite recovery.

Regadenoson cardiac stress test-induced stress cardiomyopathy

Takotsubo cardiomyopathy, also described as apical ballooning syndrome/stress-induced cardiomyopathy, imitates acute coronary syndrome and is usually related to a massive physiological or emotional stressor. We describe perhaps the first reported case to the best of our knowledge of a 55-year-old Caucasian woman who presented with congestive heart failure after having a regadenoson cardiac stress test a few hours prior to presentation to the hospital. Transthoracic echocardiogram revealed reduced heart function. She had normal coronaries on cardiac catheterisation, and left ventriculography confirmed apical ballooning syndrome. She underwent guideline-directed therapy, and heart function improved in the repeat echocardiogram along with clinical resolution of symptoms.

A case of congenital coronary-pulmonary fistulas presenting as spontaneous mediastinal haemorrhage

Coronary artery fistulas are rare anomalous vascular connections between coronary arteries and a cardiac chamber or a central vessel, without an intervening capillary bed. Coronary-pulmonary fistulas are a distinct subset of coronary artery fistulas. We present the case of a previously healthy 63-year-old-man who presented with chest pain and was found to have mediastinal haemorrhage. Upon further investigations, he was found to have multiple coronary-pulmonary fistulas with pseudoaneurysm formation in three of the fistulas. Two of these pseudoaneurysms showed inflammatory changes indicative of recent bleed. These were determined to be the source of the mediastinal bleeding and patient’s initial presentation. The patient was managed medically after obtaining multiple expert opinions from various institutions.

A warning sign

A 64year old man presented with atypical chest pain of 6h duration. Physical examination showed tachycardia and an irregularly irregular pulse. Initial EKG showed atrial fibrillation with rapid ventricular rate. Intravenous Diltiazem was administered following which there was resolution of atrial fibrillation as well as his chest pain. Troponin T and CPK-MB were minimally elevated at 0.05ng/ml (0.0-0.03ng/ml) and 8.6ng/ml (0.0-7.0ng/ml) respectively. A repeat EKG obtained after symptom resolution showed biphasic T wave inversions in V2 and V3 which prompted an emergent coronary angiogram that revealed 90% occlusion of the proximal LAD. The immediate recognition of Wellens' pattern lead to emergent coronary revascularization and prevention of acute myocardial infarction in our patient. Clinicians should be aware of this syndrome so that prompt invasive therapy can be done to avoid evolution into MI and subsequent left ventricular dysfunction.