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Chirumamilla Y, Edupuganti S, Bachuwa G, Alkotob L. Right atrial thrombus leading to pulmonary embolism in a patient with dermatomyositis and COVID-19 managed with FlowTriever device thrombectomy. BMJ Case Rep 2023; 16:e255385. [PMID: 37945279 PMCID: PMC10649501 DOI: 10.1136/bcr-2023-255385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
A woman in her late 40s presented with complaints of shortness of breath, right-sided pleuritic chest pain and diffuse myalgias. She was diagnosed with deep vein thrombosis (DVT) 3 weeks earlier and had been compliant with her oral anticoagulation therapy. Investigations revealed a pulmonary embolism (PE) involving the right distal pulmonary artery on a CT angiogram of the chest. She was also found to have an incidental SARS-CoV-2 (COVID-19) infection and an elevated creatine kinase value. Anticoagulation with intravenous heparin was initiated according to the DVT/PE protocol. The following morning, a medium-sized mobile mass was identified in her right atrium on performing a transthoracic echocardiogram. Due to concerns of embolisation of the mass which could result in obstruction, right ventricular strain and ultimately haemodynamic instability, a thrombectomy was performed using the FlowTriever device under transthoracic echocardiography guidance. The right atrial mass was successfully removed and the patient was transitioned to another oral anticoagulant agent. On discharge, a muscle biopsy was performed and aided in the diagnosis of dermatomyositis and the patient received intravenous Ig, steroids and methotrexate.
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Affiliation(s)
| | - Srujan Edupuganti
- Internal Medicine/Pediatrics, Hurley Medical Center, Flint, Michigan, USA
| | - Ghassan Bachuwa
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | - Luay Alkotob
- Department of Cardiovascular Medicine, Hurley Medical Center, Flint, MI, USA
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The diagnostic capabilities of the combined cardiac and lung point of care ultrasound in shocked patients at the emergency department - Resourced limited country. Eur J Radiol Open 2022; 9:100446. [PMID: 36250194 PMCID: PMC9554831 DOI: 10.1016/j.ejro.2022.100446] [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: 09/24/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/04/2022] Open
Abstract
Purpose Cardiac, lung, and inferior vena cava (IVC) ultrasound are commonly performed in the care of emergency patients especially patient presented with hypotension or shock. However, the literature indicated the limitation of IVC to assess shocked patients. This study aims to determine the efficacy of combined cardiac and lung ultrasound for evaluation the etiology of shock. Materials and Methods A cross-sectional study was conducted on patient with shock at emergency department, Srinagarind Hospital, Thailand, from January to December 2021. Adult shocked patients who met the criteria were included in this study. Ultrasound and emergency department medical records were documented and analyzed as sensitivity, specificity, predictive value, negative predictive value, diagnostic accuracy, and Cohen's kappa coefficient (κ). Results One hundred and two who met the criteria were enrolled. Combined cardiac and lung scans were found to be accurate 99.02% and 93.04% in obstructive and cardiogenic shock. In patients with obstructive shock was the almost perfect agreement, (κ) = 0.85. However, distributive, and hypovolemic shock had the low concordance with the final hospital diagnosis, (κ) = 0.37 and 0.43, respectively. Conclusions The integration of cardiac and lung ultrasound can be effectively used to narrow differential diagnosis of shock.
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Lyonga Ngonge A, Ganta N, Jalal Eldin A, Effoe V, Nso N, Williams D. The Dilemma in the Management of Thromboembolic Disease in the Setting of Concomitant Aortic Pseudoaneurysm. Cureus 2021; 13:e20668. [PMID: 35106211 PMCID: PMC8786573 DOI: 10.7759/cureus.20668] [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: 12/24/2021] [Indexed: 11/29/2022] Open
Abstract
Ascending aortic pseudoaneurysm (AAP) is a rare and serious complication of cardiothoracic surgeries or blunt chest trauma. We present a patient with paroxysmal atrial fibrillation, acute right pontine stroke, and acute pulmonary embolism (PE) with an incidental AAP that precluded the use of anticoagulation and surgery. The case findings substantiate the need for a CT-based assessment of aortic pathology after coronary artery bypass grafting (CABG) in the asymptomatic patient to determine the most appropriate treatment modalities. However, the high cost of CT imaging and the potential radiation exposure challenge its routine use in high-risk patients.
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Myslivecek L, Gue Y, Vasiliadis I. Case report of subacute presentation of tricuspid valve thrombus complicated by widespread bilateral pulmonary emboli: a multifactorial aetiology. Eur Heart J Case Rep 2021; 5:ytab282. [PMID: 34423246 PMCID: PMC8374983 DOI: 10.1093/ehjcr/ytab282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/27/2021] [Accepted: 06/30/2021] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Right heart thrombus (RHTh) complicated by pulmonary embolism (PE) usually presents as a medical emergency with significant haemodynamic instability. However, less is known about subacute presentations.
Case summary
We present a 74-year-old haemodynamically stable gentleman with a 3-week history of mild pleuritic chest pain and exertional dyspnoea preceded by lower respiratory tract infection. Early trans-thoracic echocardiogram (TTE) revealed a 3 cm elongated tricuspid valve thrombus with right ventricular dysfunction, new-onset atrial fibrillation, and new-onset severe left ventricular impairment. Subsequent computed tomography pulmonary angiogram showed widespread bilateral pulmonary emboli with retrograde opacification of the hepatic veins. The RHTh successfully resolved with warfarin therapy with no further complications, and the patient was discharged on Day 8 of hospitalization.
Discussion
An early TTE is crucial in detecting the RHTh in patients suspected of PE and can significantly change the management compared with uncomplicated PE. The index of suspicion for PE and RHTh should remain high even in subacute cases.
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Affiliation(s)
- Libor Myslivecek
- Hereford Cardiology, The County Hospital, Union Walk, Hereford HR1 2ER, UK
| | - Ying Gue
- Hereford Cardiology, The County Hospital, Union Walk, Hereford HR1 2ER, UK
| | - Ioannis Vasiliadis
- Hereford Cardiology, The County Hospital, Union Walk, Hereford HR1 2ER, UK
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Anfinogenova ND, Vasiltseva OY, Vrublevsky AV, Vorozhtsova IN, Popov SV, Smorgon AV, Mochula OV, Ussov WY. Right Atrial Thrombosis and Pulmonary Embolism: A Narrative Review. Semin Thromb Hemost 2020; 46:895-907. [PMID: 33368111 DOI: 10.1055/s-0040-1718399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Prompt diagnosis of pulmonary embolism (PE) remains challenging, which often results in a delayed or inappropriate treatment of this life-threatening condition. Mobile thrombus in the right cardiac chambers is a neglected cause of PE. It poses an immediate risk to life and is associated with an unfavorable outcome and high mortality. Thrombus residing in the right atrial appendage (RAA) is an underestimated cause of PE, especially in patients with atrial fibrillation. This article reviews achievements and challenges of detection and management of the right atrial thrombus with emphasis on RAA thrombus. The capabilities of transthoracic and transesophageal echocardiography and advantages of three-dimensional and two-dimensional echocardiography are reviewed. Strengths of cardiac magnetic resonance imaging (CMR), computed tomography, and cardiac ventriculography are summarized. We suggest that a targeted search for RAA thrombus is necessary in high-risk patients with PE and atrial fibrillation using transesophageal echocardiography and/or CMR when available independently on the duration of the disease. High-risk patients may also benefit from transthoracic echocardiography with right parasternal approach. The examination of high-risk patients should involve compression ultrasonography of lower extremity veins along with the above-mentioned technologies. Algorithms for RAA thrombus risk assessment and protocols aimed at identification of patients with RAA thrombosis, who will potentially benefit from treatment, are warranted. The development of treatment protocols specific for the diverse populations of patients with right cardiac thrombosis is important.
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Affiliation(s)
- Nina D Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Oksana Y Vasiltseva
- Unit of Aorta and Coronary Artery Surgery, E. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, Novosibirsk, Russia
| | - Alexander V Vrublevsky
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Irina N Vorozhtsova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Sergey V Popov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Andrey V Smorgon
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Olga V Mochula
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Wladimir Y Ussov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
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Kalivoda EJ, Rivera Rodriguez K, Cabrera G. Right Heart Thrombus in Transit Diagnosed With Focused Cardiac Ultrasound in the Emergency Department. Cureus 2020; 12:e9354. [PMID: 32850226 PMCID: PMC7444960 DOI: 10.7759/cureus.9354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The diagnosis of a right heart thrombus (RHTh) in transit associated with pulmonary embolism (PE) is an uncommon phenomenon with a high mortality rate. Timely recognition of RHTh with focused cardiac ultrasound (FOCUS) in cases of suspected PE is necessary for critical decision making in the emergency department (ED). We present a case of RHTh with submassive PE in which the patient underwent successful catheter-directed thrombolysis. This case report illustrates the significance of an emergency physician (EP) implementing FOCUS during the initial ED evaluation to rapidly diagnose RHTh in transit and initiate PE therapy without delay.
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Affiliation(s)
- Eric J Kalivoda
- Emergency Medicine, Hospital Corporation of America West Florida Graduate Medical Education Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
| | - Kevin Rivera Rodriguez
- Emergency Medicine, Hospital Corporation of America West Florida Graduate Medical Education Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
| | - Gabriel Cabrera
- Emergency Medicine, Hospital Corporation of America West Florida Graduate Medical Education Consortium/Brandon Regional Hospital, University of South Florida Morsani College of Medicine, Brandon, USA
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Kabrhel C, Rosovsky R, Garvey S. Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism. Crit Care Clin 2020; 36:531-546. [PMID: 32473697 DOI: 10.1016/j.ccc.2020.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
| | - Rachel Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Shannon Garvey
- Boston University School of Medicine, 72 E Concord Street, Boston, MA 02118, USA
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Odanovic N, Greenstein YY, Akthar M, Maher J, Waller AH, Guevarra KP. Acute Stroke in a Young Woman. Chest 2019; 154:e5-e7. [PMID: 30044752 DOI: 10.1016/j.chest.2018.01.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/22/2017] [Accepted: 01/05/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Natalija Odanovic
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Yonatan Y Greenstein
- Department of Medicine, Division of Pulmonary & Critical Care and Allergy & Immunologic Diseases, Rutgers New Jersey Medical School, Newark, NJ
| | - Morium Akthar
- Department of Medicine, Division of Pulmonary & Critical Care and Allergy & Immunologic Diseases, Rutgers New Jersey Medical School, Newark, NJ
| | - James Maher
- Department of Medicine, Division of Cardiology, Rutgers New Jersey Medical School, Newark, NJ
| | - Alfonso H Waller
- Department of Medicine, Division of Cardiology, Rutgers New Jersey Medical School, Newark, NJ
| | - Keith P Guevarra
- Department of Medicine, Division of Pulmonary & Critical Care and Allergy & Immunologic Diseases, Rutgers New Jersey Medical School, Newark, NJ.
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Keikha M, Salehi-Marzijarani M, Soldoozi Nejat R, Sheikh Motahar Vahedi H, Mirrezaie SM. Diagnostic Accuracy of Rapid Ultrasound in Shock (RUSH) Exam; A Systematic Review and Meta-analysis. Bull Emerg Trauma 2018; 6:271-278. [PMID: 30402514 PMCID: PMC6215077 DOI: 10.29252/beat-060402] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective: To perform a diagnostic accuracy of the rapid ultrasound in shock (RUSH) to diagnose the etiology of undifferentiated shock in patients presenting to the emergency department (ED). Methods: We searched the Medline via PubMed, Scopus, and ISI Web of Knowledge till July 2017. Two independent reviewers screened studies for eligibility. Our study analysis is planned in accordance with the guidelines for meta–analysis of diagnostic studies. In the systematic search, of 397 references, 295 were excluded on the basis of the title and abstract. For the remaining 102 articles, the full text was retrieved and critically reviewed. After the selection process, five papers were included. Results: The pooled estimate of all data showed that the RUSH protocol exhibited high sensitivity (0.87, 95% Confidence Interval (CI): 0.80-0.92, I2 = 46.7%) and specificity (0.98, 95% C. I.: 0.96-0.99, I2 = 30.8%). The AUC for SROC, a global measure of the RUSH protocol performance, was 0.98 ± 0.01, indicates the high accuracy of the test. Positive and negative likelihood ratios reported from the studies ranged from 9.83 to 51.32 and 0.04 to 0.33, respectively. The pooled estimate of all data showed that the RUSH protocol exhibited high positive likelihood ratio (19.19, 95% C. I.: 11.49-32.06, I2 = 14.1%) and low negative likelihood ratio (0.23, 95% C. I.: 0.15-0.34, I2 = 18.4%). Conclusion: This meta-analysis suggests that RUSH protocol has generally good role to distinguish the states of shock in patients with undifferentiated shock referred to the emergency department.
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Affiliation(s)
- Mojtaba Keikha
- Department of Epidemiology, School of Public Health, Shahroud University of Medical Sciences, Shahroud, Iran
| | | | - Reihane Soldoozi Nejat
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | | | - Seyed Mohammad Mirrezaie
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
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