Paradoxical embolism causing acute embolic events in a patient with hereditary thrombophilia

A Case of Paradoxical Embolism Causing Anterior Spinal Cord Syndrome and Acute Myocardial Infarction Following the Intradiscal Oxygen-Ozone Therapy

We report a case of a 66-year-old female who burst into flaccid paralysis of the lower extremities, accompanied by loss of pain and temperature sensation below T4 level, during an oxygen–ozone injection for disc herniation. Half an hour later, she suffered from chest pain. Magnetic resonance imaging (MRI) showed long segment hyperintensity in the thoracic spinal cord from T2 to 10 level on sagittal T2-weighted images (T2WI). The electrocardiogram (ECG) showed ST-segment elevation in V1–V6 leads. She was diagnosed with spinal cord infarction and ST-elevation myocardial infarction (STEMI). Transthoracic echocardiography with saline contrast showed existence of a large patent foramen ovale (PFO) correlating with the detection of massive microbubbles in the left atrium. We discuss the potential role of paradoxical embolism in spinal cord infarction and myocardial infarction.

Serum D-dimer is a potential predictor for thromboembolism complications in patients with renal biopsy

Renal biopsy has been widely recommended in clinic to determine the histological patterns of kidney disease. To prevent bleeding complications, patients should routinely stop anticoagulants prior to renal biopsy. However, patients with kidney disease are susceptible to thromboembolisms, particularly in those with severe hypoalbuminemia. This study was designed to investigate the application of serum D-dimer as a predictor for thrombotic events after renal biopsy. 400 consecutive native renal biopsies were prospectively included in this 2-month follow-up study. The overall incidence of bleeding and thrombotic complication is 4%, including hematuria or large perinephric hematoma (2.5%, n = 10) and thrombotic complication (1.5%, n = 6). Compared to low serum D-dimer (<2.00 μg/ml), subjects in the group of high serum D-dimer (≥2.00 μg/ml) were more incline to develop thrombotic complications (9.1% versus 0.3%; RR, 30.33; p < 0.001). D-dimer correlated positively with age (r_s = 0.258, P < 0.001). Inverse correlations were found for albumin (r_s = −0.339, P < 0.001). Taken together, patients with high serum D-dimer carry an increased risk of thrombotic complications after renal biopsy. Our findings suggest that serum D-dimer can serve as a potential predictor for thrombotic events in patients with kidney disease. Further cautions should be given to these subjects.

ST-segment elevation in V1-V4 in acute pulmonary embolism: a case presentation and review of literature

INTRODUCTION

Electrocardiographic (ECG) abnormalities are seen in 70%-80% of patients with acute pulmonary embolism (APE). Rarely, APE presents with ST-segment elevation (STE) in leads V1-V4, mimicking ST-segment elevation myocardial infarction (STEMI). Herein, we describe a case of APE presenting with STE in V1-V3, along with a comprehensive review of the literature.

METHODS

We reviewed Pubmed/Medline indexed articles from 1950 to 2014 reporting cases of APE presenting with STE in V1-V3 or V4 (V1-V3/V4). Cases were analyzed with specific reference to patient demographics, clinical, laboratory, and radiological data, treatment, and outcome.

RESULTS

A total of 12 cases were identified comprising seven males and five females aged between 31 and 64 years. Five cases met the American College of Cardiology/American Heart Association criteria for massive APE due to sustained hemodynamic instability or requirement for inotropic support, and seven met criteria for submassive PE due to right ventricular (RV) dysfunction or elevated troponin in absence of systemic hypotension. Among the notable clinical features in this cohort is the high incidence of syncope, in 66.7% of the cases, high incidence of concomitant deep venous thrombosis (DVT) in 90% of cases that reported venous Doppler results (eight proximal and one distal DVT), and the presence of a dilated RV in 90% of the cases that reported echocardiographic results. In all but one case the initial working diagnosis was STEMI and emergent cardiac catheterization was planned. In the 90% of cases who eventually had a coronary angiography, the angiogram was performed prior to diagnosing APE, and the lack of occlusive disease prompted further workup that confirmed the diagnosis of APE. In-hospital mortality rate in the studied population was 16.7%.

CONCLUSION

STE in leads V1-V3/V4 in cases with APE identifies a subset of patients who are an intermediate to high risk category. In cases presenting with right precordial lead STE and clinical features that are more suggestive of APE rather than STEMI, a computed tomography pulmonary angiogram is warranted for earlier diagnosis of suspected APE, which allow for immediate-rather than delayed-initiation of therapeutic anticoagulant therapy if the diagnosis is confirmed and may avert the need for coronary angiography.

Electrocardiogram patterns during hemodynamic instability in patients with acute pulmonary embolism

BACKGROUND

We have previously described new electrocardiogram (ECG) findings for massive pulmonary embolism, namely ST-segment elevation in lead aVR with ST-segment depression in leads I and V4 -V6 . However, the ECG patterns of patients with acute pulmonary embolism during hemodynamic instability are not fully described.

METHODS

We compared the differences between the ECG at baseline and after deterioration during hemodynamic instability in twenty patients with acute pulmonary embolism.

RESULTS

Compared with the ECG at baseline, three ischemic ECG patterns were found during clinical deterioration with hemodynamic instability: ST-segment elevation in lead aVR with concomitant ST-segment depression in leads I and V4 -V6 , ST-segment elevation in leads V1 -V3 /V4 , and ST-segment elevation in leads III and/or V1 /V2 with concomitant ST-segment depression in leads V4 /V5 -V6 . Ischemic ECG patterns with concomitant S1Q3 and/or abnormal QRS morphology in lead V1 were more common (90%) during hemodynamic instability than at baseline (5%) (P = 0.001).

CONCLUSIONS

Hemodynamic instability in acute pulmonary embolism is reflected by signs of myocardial ischemia combined with the right ventricular strain pattern in the 12-lead ECG.