1
|
Sera S, Okazaki Y, Kashiwa K, Ichiba T. A Case Report of Under-Recognized Conditions in Pulmonary Embolism: Patent Foramen Ovale and Right Ventricular Thrombus. Cureus 2024; 16:e52535. [PMID: 38371032 PMCID: PMC10870038 DOI: 10.7759/cureus.52535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that presents with a spectrum of clinical symptoms ranging from asymptomatic to hemodynamic instability. The early diagnosis in the emergency department is often challenging. Although the association between patent foramen ovale (PFO) and thromboembolic events in patients with PE is well-documented, the significance of the presence of PFO in patients with PE may be underrecognized. In addition, the occurrence of right ventricular thrombus (RVT) in PE is a rare but significant complication with implications for disease management. We report a case of acute-on-chronic PE with concurrent bilateral renal infarction due to a paradoxical embolus, alongside RVT. A 35-year-old male presented at our emergency department with complaints of sudden onset abdominal pain. Bilateral renal infarction was identified on a contrast-enhanced computed tomography (CT). Point-of-care ultrasound showed suggestive findings of PE and RVT. Subsequently, a pulmonary CT angiography confirmed bilateral PE, a PFO, and RVT. The patient was effectively managed with thrombolytic therapy, with extracorporeal membrane oxygenation on standby. This case highlights the need to recognize the diverse clinical manifestations of PE and the importance of considering coexisting PFO and RVT in affected patients. The diagnosis of PE can be complex when symptoms overlap with arterial thrombosis, such as renal infarction secondary to a PFO. In addition, RVT, although uncommon, is a serious complication in patients with PE that may require careful evaluation for thrombolytic or anticoagulant therapy. It is critical to consider the possibility of a PFO in all cases of PE, even in the absence of arterial embolism, and to promptly evaluate for RVT prior to initiating treatment.
Collapse
Affiliation(s)
- Satoshi Sera
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Yuji Okazaki
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Kenichiro Kashiwa
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| |
Collapse
|
2
|
Bhandari J, Abbas AM, Alfarone JJ, Huda S, Ojha N. The Discovery of an Intracardiac Thrombus Following a Mild COVID-19 Infection: A Case Report and Review of Literature. Cureus 2023; 15:e39745. [PMID: 37398759 PMCID: PMC10310549 DOI: 10.7759/cureus.39745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19) is a viral disease that predominantly affects the respiratory system, but extrapulmonary manifestations have been increasingly reported over the course of the pandemic. Common extrapulmonary manifestations include the gastrointestinal, cardiovascular, and neurological systems, such as diarrhea, rashes, loss of smell/taste, myalgia, acute kidney injury, cardiac arrhythmias, or heart failure. COVID-19 infection is associated with an increased risk of thromboembolic events, especially in the setting of severe disease. We present a case of a 42-year-old female who recently tested positive for COVID-19 infection and presented to the clinic with complaints of palpitations that started after her diagnosis. An electrocardiogram done in the clinic showed sinus rhythm, and the patient was placed on an event monitor, which showed no evidence of tachyarrhythmia. A transthoracic echocardiogram (TTE) done as part of the workup showed a large thrombus in the right ventricular outflow tract attached to the ventricular side of the pulmonic valve. The patient was started on a therapeutic dose of apixaban at 10 mg twice a day (BID) for seven days and 5 mg twice a day afterward.
Collapse
Affiliation(s)
| | - Anas M Abbas
- Medicine, Norton College of Medicine, Upstate University Hospital, Syracuse, USA
| | - John J Alfarone
- Medicine, Norton College of Medicine, Upstate University Hospital, Syracuse, USA
| | - Syed Huda
- Cardiology, Upstate University Hospital, Syracuse, USA
| | - Niranjan Ojha
- Cardiology, Upstate University Hospital, Syracuse, USA
| |
Collapse
|
3
|
Sharma A, Machanahalli Balakrishna A, Sharma A, Slattery T. Right atrial appendage thrombus in a patient with a left atrial appendage occlusion device. Proc AMIA Symp 2022; 35:520-521. [DOI: 10.1080/08998280.2022.2065104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Arindam Sharma
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | | | - Arunima Sharma
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
4
|
Hulkoti V, Kamat S, Acharya S, Shukla S, Kumar S, Talwar D. Serpentine Thrombus in Right Atrium: A Tell-Tale Sign of Venous Thromboembolism. Cureus 2021; 13:e20336. [PMID: 35028228 PMCID: PMC8743344 DOI: 10.7759/cureus.20336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/15/2022] Open
Abstract
Pulmonary embolism is linked with a remarkable rate of mortality, particularly when it is associated with hemodynamic instability, right atrial thrombus and related right ventricular dysfunction. In patients affected with pulmonary embolism, thrombolysis has been documented to be life-saving. The administration of thrombolytic agents ensures early resolution of the thrombus and prevents arrhythmia and cardiogenic shock. Streptokinase, urokinase and alteplase are among the three thrombolytic agents approved for the treatment of pulmonary embolism. In emergency situations, thrombectomy plays a crucial role.
Collapse
|
5
|
A 51-Year-Old Man With Right Atrial Neoplasm Presenting With Syncope and Shock. Chest 2021; 160:e237-e241. [PMID: 34366051 DOI: 10.1016/j.chest.2020.08.2141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 06/17/2020] [Accepted: 08/10/2020] [Indexed: 11/22/2022] Open
|
6
|
Brown A, Abbas M, Runnett C, Ripley DP. Listeria myopericarditis associated with right atrial mural thrombus: a case report. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 32974471 PMCID: PMC7501928 DOI: 10.1093/ehjcr/ytaa145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/23/2019] [Accepted: 05/05/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pericarditis is a common cardiology presentation, most often due to a viral or idiopathic cause. Listeria as a cause of pericarditis is rare. Listeria is an infection that is readily treatable with antibiotics following accurate identification. Without adequate treatment, Listeria infection has a high mortality rate. CASE SUMMARY In this case, a fit and well 59-year-old man complained of headaches and fever to the emergency department (ED). He was provisionally diagnosed with giant cell arteritis (GCA) and commenced on management pathways for GCA. He represented to the ED with chest pain and electrocardiogram (ECG) changes suggestive of a clinical presentation of pericarditis. He received treatment for idiopathic pericarditis with no clinical resolution. Cardiac magnetic resonance imaging (MRI) showed myopericardial inflammation associated with a right atrial mural thrombus. After 2 weeks of poor treatment response, peripheral blood cultures grew Listeria monocytogenes and the patient responded well to antibiotic treatment. Repeat cardiac MRI after an extended course of antibiotics showed resolution of MRI signs. DISCUSSION This is a case of Listeria myopericarditis. Physicians should consider rarer causes of myopericarditis in treatment resistance cases. Cardiac MRI has utility in atypical or treatment resistant patients to assess myopericardial inflammation and response to treatment.
Collapse
Affiliation(s)
- Andrew Brown
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, Northumbria Specialist Care Emergency Hospital, Northumbria Way, Northumberland NE23 6NZ, UK
| | - Mohamed Abbas
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, Northumbria Specialist Care Emergency Hospital, Northumbria Way, Northumberland NE23 6NZ, UK
| | - Craig Runnett
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, Northumbria Specialist Care Emergency Hospital, Northumbria Way, Northumberland NE23 6NZ, UK
| | - David Paul Ripley
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, Northumbria Specialist Care Emergency Hospital, Northumbria Way, Northumberland NE23 6NZ, UK
| |
Collapse
|
7
|
Elkattawy S, Younes I, Noori MAM. A Case Report of Polymerase Chain Reaction-Confirmed COVID-19 in a Patient With Right Ventricular Thrombus and Bilateral Deep Vein Thrombosis. Cureus 2020; 12:e8633. [PMID: 32685302 PMCID: PMC7364394 DOI: 10.7759/cureus.8633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/15/2020] [Indexed: 11/05/2022] Open
Abstract
The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that causes the highly contagious coronavirus disease 2019 (COVID-19) has led to an unprecedented global health crisis. Infected patients have been shown to trigger a heightened inflammatory response, increasing thrombotic risk. We report the case of a polymerase chain reaction (PCR)-confirmed COVID-19 in a Hispanic male with no past medical history who presented to the ED with upper respiratory tract symptoms including shortness of breath and cough, requiring continuous positive airway pressure (CPAP) therapy. He was found to have a right ventricular thrombus (RVT) and bilateral deep vein thrombosis (DVT) on the day of admission, which were detected on transthoracic echocardiogram and duplex venous ultrasound, respectively. The patient was started on therapeutic enoxaparin sodium, which led to an improvement in oxygenation, and he was eventually downgraded to the medical floors for further management.
Collapse
Affiliation(s)
- Sherif Elkattawy
- Internal Medicine, Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | - Islam Younes
- Internal Medicine, Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | - Muhammad Atif Masood Noori
- Internal Medicine, Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
- Internal Medicine, Dow Medical College, Karachi, PAK
| |
Collapse
|
8
|
Secco G, Falchi AG, Salinaro F, Blatti C, Giacomuzzi Moore B, Perlini S. Pulmonary hypertension: when the acute event leads to diagnosis. Case report in a patient with Ehlers-Danlos syndrome. EMERGENCY CARE JOURNAL 2020. [DOI: 10.4081/ecj.2020.8310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a pulmonary vascular pathology caused by the chronic obstruction of the major pulmonary arteries, usually being the consequence of recurrent episodes of pulmonary embolism. Such events are usually unknown; the delay in such a diagnosis can therefore lead to a deterioration of the clinical picture, worsening the overall prognosis. This is a case of a 55-year-old man who came to the Emergency Room (ER) because of an acute exacerbation of chronic dyspnea, that he experienced for several years, in the absence of an explanatory diagnosis. Acute pulmonary embolism was diagnosed in the setting of the ER, with bedside echography resulting to be crucial to the work up. A multidisciplinary approach allowed proper treatment, management and a favourable outcome.
Collapse
|
9
|
Wong B, Glenie T, Merriman E, Edwards C. Extensive intracardiac thrombi in a patient with heart failure and hepatic congestion: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2018; 3:yty159. [PMID: 31020235 PMCID: PMC6439363 DOI: 10.1093/ehjcr/yty159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/01/2018] [Indexed: 11/13/2022]
Abstract
Background Left ventricular (LV) thrombi is a complication associated with anterior ST-elevation myocardial infarction, dilated cardiomyopathies, or LV aneurysms. Right sided intracardiac thrombi may be associated with other prothrombotic causes. Case summary A 66-year-old man admitted with congestive heart failure was found to have extensive intracardiac masses on transthoracic echocardiography and cardiac magnetic resonance imaging (MRI). This occurred in the absence of a recent myocardial infarction. During his hospital stay, he was found to have deranged liver enzymes and coagulation profile due to hepatic congestion. The patient was presumed to have intracardiac thrombi and was treated with warfarin therapy. There was complete resolution of the masses on repeat cardiac MRI after 4 weeks of treatment, confirming the diagnosis. Discussion Cardiac MRI is useful in the diagnosis of intracardiac thrombi. Clinicians should appreciate the prothrombotic risks associated with liver disease, despite the inability of standard coagulation tests to quantify this risk.
Collapse
Affiliation(s)
- Bernard Wong
- Department of Cardiology, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland, New Zealand
| | - Timothy Glenie
- Department of Cardiology, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland, New Zealand
| | - Eileen Merriman
- Department of Haematology, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland, New Zealand
| | - Colin Edwards
- Department of Cardiology, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland, New Zealand
| |
Collapse
|
10
|
Bhagat A, Annie FH, Tager A, Nanjundappa A, Adams C. Alternative Treatment Approach for Right Heart Masses. Cureus 2018; 10:e3673. [PMID: 30761226 PMCID: PMC6367113 DOI: 10.7759/cureus.3673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The traditional therapeutic approach for heart masses has been surgical resection. For right-sided masses, percutaneous mechanical thrombectomy (PMT) is a viable treatment option which is being applied with increasing frequency. This newer treatment modality is less invasive, less expensive, and results in shorter hospital stays compared to cardiac surgery. We demonstrate below a case in which rheolytic PMT was utilized successfully, allowing the patient to be discharged the following day.
Collapse
Affiliation(s)
- Abhishek Bhagat
- Internal Medicine, Charleston Area Medical Center, Charleston, USA
| | - Frank H Annie
- Cardiology, Charleston Area Medical Center, Charleston, USA
| | - Alfred Tager
- Emergency Medicine, Charleston Area Medical Center, Charleston, USA
| | - Aravinda Nanjundappa
- Cardiology, Charleston Area Medical Center / West Virginia University, Charleston, USA
| | | |
Collapse
|
11
|
Bikdeli B, Lobo JL, Jiménez D, Green P, Fernández‐Capitán C, Bura‐Riviere A, Otero R, DiTullio MR, Galindo S, Ellis M, Parikh SA, Monreal M. Early Use of Echocardiography in Patients With Acute Pulmonary Embolism: Findings From the RIETE Registry. J Am Heart Assoc 2018; 7:e009042. [PMID: 30371152 PMCID: PMC6201438 DOI: 10.1161/jaha.118.009042] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/22/2018] [Indexed: 12/19/2022]
Abstract
Background Transthoracic echocardiography ( TTE ) is often considered for risk stratification of patients with acute pulmonary embolism ( PE ). We sought to determine the contemporary utilization of early TTE (within 72 hours of PE diagnosis) and explored the association between TTE findings and PE -related mortality. Methods and Results Data from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry, a multicenter registry of consecutive patients with acute PE , were used (2001-July 2017). We used a generalized linear mixed model to determine predictors of early TTE performance. Moreover, the association between 3 TTE variables (right atrial enlargement, right ventricular hypokinesis, and presence of right heart thrombi) and 30-day PE -related mortality was assessed in generalized linear mixed models adjusted for PE severity index, and other comorbidities. Among 35 935 enrollees with acute PE , 15 375 (42.8%) underwent early TTE . There was an increase in early TTE utilization rate over time ( P<0.001 for trend). Younger age, female sex, enrollment in countries other than Spain, history of coronary disease, heart failure, atrial fibrillation, tachycardia, and hypotension were the main predictors of early TTE ( P<0.01 for all). In multivariable analyses, right atrial enlargement (adjusted odds ratio: 3.74; 95% confidence interval, 2.10-6.66), right ventricular hypokinesis (adjusted odds ratio: 3.11, 95% confidence interval: 1.85-5.21) and right heart thrombi (adjusted odds ratio: 4.39, 95% confidence interval, 1.99-9.71) were associated with increased odds for PE -related mortality. Conclusions Early TTE is commonly performed for acute PE and utilization rates have increased over time. Right atrial enlargement, right ventricular hypokinesis, and right heart thrombi are predictive of worse outcomes. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02832245.
Collapse
Affiliation(s)
- Behnood Bikdeli
- Division of CardiologyDepartment of MedicineColumbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
- Yale/YNHH Center for Outcomes Research & EvaluationNew HavenCT
| | - José Luis Lobo
- Department of PneumonologyHospital Universitario ArabaÁlavaSpain
| | - David Jiménez
- Respiratory DepartmentHospital Ramón y CajalMadridSpain
- Medicine DepartmentUniversidad de Alcalá (IRYCIS)MadridSpain
| | - Philip Green
- Division of CardiologyDepartment of MedicineColumbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | | | | | - Remedios Otero
- Department of PneumonologyHospital Universitario Virgen del RocíoSevilleSpain
| | - Marco R. DiTullio
- Division of CardiologyDepartment of MedicineColumbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | | | - Martin Ellis
- Department of HaematologyMeir HospitalKfar SabaIsrael
| | - Sahil A. Parikh
- Division of CardiologyDepartment of MedicineColumbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Manuel Monreal
- Hospital Universitari Germans Trias i PujolBadalona, BarcelonaSpain
| |
Collapse
|
12
|
Abstract
RATIONALE Syncope is a complicated clinical condition involving various diseases. Syncope due to myxoma-like right atrial thrombus is rarely seen in patient without structural heart disease. PATIENT CONCERNS A 61-year-old ambulant old male visited our emergency department for sudden syncope. DIAGNOSES After the exclusion of neurological and coronary diseases, a right atrial block mass with a stalk connected to the atrial septum was accidentally found by echocardiography. Pulmonary embolism was subsequently revealed by computed tomographic pulmonary angiography. Atrial myxoma was initially suspected and surgical removal was conducted. Surprisingly, histological examination showed that the pedicled block mass was actually thrombus. INTERVENTIONS The myxoma-like right atrial thrombus and the emboli in the bilateral pulmonary trunks were resected. This patient received anticoagulant treatment with warfarin for 6 months additionally. OUTCOMES The patient was successfully discharged and being continually followed. CONCLUSION This patient had a past medical history of right femoral neck fracture, which might be responsible for the formation of the myxoma-like right atrial thrombus. We should always consider echocardiography examination in syncope patient at risk of thrombus formation.
Collapse
Affiliation(s)
| | - Zhenjie Gu
- Department of Cardiology, Maoming People's Hospital, Maoming, China
| |
Collapse
|
13
|
AbuHalimeh B, Desai MY, Tonelli AR. Effect of abnormal right heart structures on the diagnosis of pulmonary hypertension. Pulm Circ 2018; 8:2045894018773053. [PMID: 29671686 PMCID: PMC5946618 DOI: 10.1177/2045894018773053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The diagnosis of pulmonary hypertension (PH) requires a right heart catheterization (RHC) that reveals a mean pulmonary artery pressure ≥ 25 mmHg. The pulmonary artery catheter traverse the right atrium and ventricle on its way to the pulmonary artery. The presence of abnormal right heart structures, i.e. thrombus, vegetation, benign or malignant cardiac lesions, can lead to complications during this procedure. On the other hand, avoidance of RHC delays the diagnosis and treatment of PH, an approach that might be associated with worse outcomes. This paper discusses the impact of right heart lesions on the diagnosis of PH and suggests an approach on how to manage this association.
Collapse
Affiliation(s)
- Batool AbuHalimeh
- 1 2569 Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, USA
| | - Milind Y Desai
- 2 2569 Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- 1 2569 Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, USA.,3 Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
14
|
Gülan U, Saguner A, Akdis D, Gotschy A, Manka R, Brunckhorst C, Holzner M, Duru F. Investigation of Atrial Vortices Using a Novel Right Heart Model and Possible Implications for Atrial Thrombus Formation. Sci Rep 2017; 7:16772. [PMID: 29196688 PMCID: PMC5711865 DOI: 10.1038/s41598-017-17117-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/22/2017] [Indexed: 11/15/2022] Open
Abstract
The main aim of this paper is to characterize vortical flow structures in the healthy human right atrium, their impact on wall shear stresses and possible implications for atrial thrombus formation. 3D Particle Tracking Velocimetry is applied to a novel anatomically accurate compliant silicone right heart model to study the phase averaged and fluctuating flow velocity within the right atrium, inferior vena cava and superior vena cava under physiological conditions. We identify the development of two vortex rings in the bulk of the right atrium during the atrial filling phase leading to a rinsing effect at the atrial wall which break down during ventricular filling. We show that the vortex ring formation affects the hemodynamics of the atrial flow by a strong correlation (ρ = 0.7) between the vortical structures and local wall shear stresses. Low wall shear stress regions are associated with absence of the coherent vortical structures which might be potential risk regions for atrial thrombus formation. We discuss possible implications for atrial thrombus formation in different regions of the right atrium.
Collapse
Affiliation(s)
- Utku Gülan
- ETH Zurich, Institute of Environmental Engineering, Zurich, 8093, Switzerland.
| | - Ardan Saguner
- University Heart Center, Department of Cardiology, Zurich, 8091, Switzerland
| | - Deniz Akdis
- University Heart Center, Department of Cardiology, Zurich, 8091, Switzerland
| | - Alexander Gotschy
- University Heart Center, Department of Cardiology, Zurich, 8091, Switzerland.,Institute for Biomedical Engineering, University and ETH Zurich, Zurich, 8092, Switzerland
| | - Robert Manka
- University Heart Center, Department of Cardiology, Zurich, 8091, Switzerland
| | - Corinna Brunckhorst
- University Heart Center, Department of Cardiology, Zurich, 8091, Switzerland
| | - Markus Holzner
- ETH Zurich, Institute of Environmental Engineering, Zurich, 8093, Switzerland
| | - Firat Duru
- University Heart Center, Department of Cardiology, Zurich, 8091, Switzerland.,Center for Integrative Human Physiology, University of Zurich, Zurich, 8091, Switzerland
| |
Collapse
|
15
|
Habibi R, Altamirano AJ, Dadkhah S. Clot in Lung, Clot in Heart: A Case Report of Tumor-Like Thrombus in Right Atrium. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2017; 10:1179547617698460. [PMID: 28579859 PMCID: PMC5415351 DOI: 10.1177/1179547617698460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 01/30/2017] [Indexed: 11/15/2022]
Abstract
Tumor-like formation of thrombus in the right atrial cavity is rare. It may be mistaken for a myxoma. The exact pathophysiology of an isolated thrombus in the heart is still unclear. Management to prevent complications such as pulmonary thromboembolism depends on the clinical judgment of a cardiologist. This report describes a 76-year-old woman with right atrial thrombus causing subsequent pulmonary thromboembolism in right lung. She initially presented to us with pulmonary embolism, and later, an incidental finding of a mass in her right atrium revealed an association of thrombus in heart with thrombus in lung. The challenging management was to resect this thrombus which was fixed to atrial septum, and a trial of anticoagulation did not resolve it. Exact management of such incidental findings in right heart cavities is not well established. Some cases may benefit from resection of such formed fixed thrombus.
Collapse
Affiliation(s)
- Roshanak Habibi
- Department of Internal Medicine, Presence Saint Francis Hospital, Evanston, IL, USA
| | - Alvaro J Altamirano
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Shahriar Dadkhah
- Department of Cardiology, Presence Saint Francis Hospital, Evanston, IL, USA
| |
Collapse
|
16
|
Vaideeswar P, Chaudhari J, Karnik N, Sahu T, Gupta A. Right atrial mural thrombi: An autopsy study of an under-diagnosed complication at an unusual site. J Postgrad Med 2016; 63:21-23. [PMID: 27652987 PMCID: PMC5394812 DOI: 10.4103/0022-3859.191008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background: Right atrial mural thrombi (RAMT) are often seen in association with cardiac diseases or foreign bodies. Unusual locations at the flutter isthmus and the atrial appendage prompted us to evaluate our 2-year autopsy data on such thrombi. Materials and Methods: In the 2-year retrospective autopsy, the clinical and autopsy records of patients with RAMT were reviewed, with particular reference to the presence of central venous catheter (CVC), its site of insertion, its type, material and size, its duration of placement, and the drugs infused through the catheter. Results: Of the 940 autopsies performed in 2 years, RAMT was seen in 24 hearts and was related to an insertion of a CVC in 23 patients (95.8%). The risk and/or associated factors for this complication were tunneled and polyethylene catheters, Intensive Care Unit admission, infused drugs, underlying cardiac diseases, and pregnancy. A noteworthy feature was the location of the thrombi in the flutter isthmus in 16 hearts (66.7%) and atrial appendage in another six hearts. Localized endocarditis/myocarditis and pulmonary thromboembolism were observed in six and four patients, respectively. Conclusions: This autopsy study, which has a high incidence of catheter-related RAMT, does not reflect the true incidence but reiterates the importance of guided insertion of central venous and prompt recognition of thrombus formation.
Collapse
Affiliation(s)
- P Vaideeswar
- Department of Pathology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - J Chaudhari
- Department of Medicine, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - N Karnik
- Department of Medicine, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - T Sahu
- Department of Pathology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - A Gupta
- Department of Medicine, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| |
Collapse
|
17
|
Surgical Treatment of Acute Massive Pulmonary Embolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:75-88. [DOI: 10.1007/5584_2016_107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
18
|
Mobile Intracardiac Mass after Inguinal Hernia Repair: An Unresolved Treatment Dilemma. Case Rep Cardiol 2015; 2015:375089. [PMID: 26351587 PMCID: PMC4553172 DOI: 10.1155/2015/375089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 06/02/2015] [Accepted: 06/08/2015] [Indexed: 11/17/2022] Open
Abstract
Right heart thrombi (RHT) are rare but well-described entity in literature. Their isolation has been considered as confirmatory for the diagnosis of venous thromboembolism (VTE). Even though their isolation aids the diagnosis, physicians are faced with a difficult management dilemma giving the paucity of data to support any treatment decision. We present a case of RHT in an 81-year-old man who presented to hospital with a large mobile right heart thrombus in transit seen on transthoracic echocardiogram (TTE). He was successfully treated with anticoagulation alone. This case highlights the importance of TTE in establishing the diagnosis and describes the interplay of factors influencing treatment decision.
Collapse
|
19
|
Condliffe R, Elliot CA, Hughes RJ, Hurdman J, Maclean RM, Sabroe I, van Veen JJ, Kiely DG. Management dilemmas in acute pulmonary embolism. Thorax 2013; 69:174-80. [PMID: 24343784 PMCID: PMC3913120 DOI: 10.1136/thoraxjnl-2013-204667] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Physicians treating acute pulmonary embolism (PE) are faced with difficult management decisions while specific guidance from recent guidelines may be absent. Methods Fourteen clinical dilemmas were identified by physicians and haematologists with specific interests in acute and chronic PE. Current evidence was reviewed and a practical approach suggested. Results Management dilemmas discussed include: sub-massive PE, PE following recent stroke or surgery, thrombolysis dosing and use in cardiac arrest, surgical or catheter-based therapy, failure to respond to initial thrombolysis, PE in pregnancy, right atrial thrombus, role of caval filter insertion, incidental and sub-segmental PE, differentiating acute from chronic PE, early discharge and novel oral anticoagulants. Conclusion The suggested approaches are based on a review of the available evidence and guidelines and on our clinical experience. Management in an individual patient requires clinical assessment of risks and benefits and also depends on local availability of therapeutic interventions.
Collapse
Affiliation(s)
- Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, , Sheffield, UK
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Agarwal V, Nalluri N, Shariff MA, Akhtar MS, Olkovsky Y, Kitsis PE, Nabagiez JP. Large embolus in transit - an unresolved therapeutic dilemma (case report and review of literature). Heart Lung 2013; 43:152-4. [PMID: 24041566 DOI: 10.1016/j.hrtlng.2013.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/02/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
Abstract
Floating right heart thrombus, also known as "emboli in transit" is a potentially fatal condition, of varying etiology and usually coexisting with massive pulmonary embolism. Although the mortality rate is as high as 40%, there are no established therapeutic guidelines. A case is presented of an 84 year old female with a history of colon cancer and coronary artery disease who presented with sudden onset unresponsiveness. She was intubated in the ED and started on intravenous pressor support. A free floating large right ventricular thrombus and dilated right ventricle were noted on transthoracic echocardiogram (TTE). She was managed medically with good short term outcome. Floating right heart thrombus is a rare occurrence. Recognition of signs and symptoms along with early TTE is critical for diagnosis and consideration of treatment modality. The existing literature does not offer a clear consensus for management of pulmonary embolism with co-existing mobile intra-cardiac thrombus. Choice of treatment is crucial and should be considered on a case-by-case basis after careful assessment of indications, contraindications, risks and benefits.
Collapse
Affiliation(s)
- Vratika Agarwal
- Department of Medicine, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305, USA.
| | - Nikhil Nalluri
- Department of Medicine, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - Masood A Shariff
- Department of Cardiothoracic Research, Staten Island University Hospital, Staten Island, NY, USA
| | - Muhammad S Akhtar
- Department of Cardiology, Staten Island University Hospital, Staten Island, NY, USA
| | - Yefim Olkovsky
- Department of Cardiology, Staten Island University Hospital, Staten Island, NY, USA
| | - Paul E Kitsis
- Department of Critical Care Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - John P Nabagiez
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA
| |
Collapse
|