Low dose peripheral systemic thrombolysis for treatment of intermediate-high risk acute pulmonary embolism: a case series

Background

The management of intermediate-high-risk acute pulmonary embolism (PE) is controversial with increasing interest in more aggressive treatment approaches than anticoagulation alone.

Case summary

We describe the case series of four consecutive patients who presented to emergency room for acute shortness of breath. They were diagnosed with intermediate-high-risk acute PE based on the computed tomography pulmonary angiography and transthoracic echocardiography (TTE) findings and the elevated simplified PE score index. They received bolus of 5 mg thrombolytics recombinant tissue plasminogen activator (rtPA) administered through peripheral intravenous (i.v.) line followed by continuous infusion at a rate of 2 mg/h along with unfractionated heparin (UFH) at a rate of 500 mg/h for additional ≤10 h. There after the dose of UFH was increased to reach a therapeutic level. Rapid clinical improvement and also improvement in TTE parameters were noted at discharge. Patients were discharged home on oral anticoagulation.

Discussion

Intermediate-high-risk acute PE carries increased risk of mortality and morbidities. Catheter-directed thrombolysis uses a low rtPA dose for local thrombolysis and is associated with low bleeding risk; however it is expensive and requires expertise and human resources. Low-dose rtPA through a peripheral i.v. line might be safe and effective in the treatment of patient with intermediate-high-risk acute PE. This therapeutic approach is readily available at most medical centres, can be started in the emergency room (ER), and can be alternative to catheter-directed thrombolysis nowadays during the COVID-19 era and in hospitals at the periphery and with limited resources.

Tip fracture of the crown of orbital atherectomy device in angulated left circumflex lesion

Atherectomy, whether rotational or orbital, is an essential and established method for treatment of calcified coronary lesions. By modifying the plaque, atherectomy lessens the risk of plaque shift and facilities stent delivery and stent expansion. Atherectomy technique is meticulous and challenging especially in tortuous and angulated coronary arteries. Herein, we describe the rare case of occurrence and the management of fracture of the tip of the crown of CSI Diamondback orbital atherectomy device during treatment of severely angulated and calcified ostial left circumflex lesion.

High Output Heart Failure Secondary to Aorto-Caval Fistula Treated With an Amplatzer Septal Occluder: Case Report and Review of Literature

Aorto-caval fistula (ACF) is a rare cause of high output heart failure (HOHF). 80 % of cases are due to ruptured abdominal aortic aneurysm, while 10 to 20% are traumatic or congenital. Early diagnosis and treatment are crucial in order to prevent the progression to HOHF. Open surgical repair has been the mainstay therapy of arterio-venous fistulas including aorto-caval fistula; however endovascular approach has become an evolving therapeutic option in the last 20 years. Here, we present a case of high output heart failure secondary to traumatic aorto-caval fistula due to shrapnel injury to the abdomen. Our patient was managed with endovascular approach by the deployment of amplatzer septal occluder that excluded completely the fistula, resulting in the progressive improvement of HOHF. In this manuscript, we review etiologies of high output heart failure and summarize cases of aorto-caval fistula treated with amplatzer septal occluder reported in literature. We also highlight the importance of this endovascular device in the presence of metallic foreign body in the aorta.

Infolding of Self-Expandable Transcatheter Heart Valve: Case Report and Review of Literature

Transcutaneous aortic valve replacement (TAVR) has become a widely accepted minimally invasive approach for treatment of severe aortic stenosis. Self-expandable prostheses are commonly the device of choice, with excellent procedural success and durability. However, there have been several recent case reports of infolding of the self-expandable prosthesis during development with subsequent malfunction and need for further intervention. We present a case of self-expandable valve prosthesis infolding managed by balloon postdilation, and summarize the cases reported in the literature to date in an attempt to increase awareness of this serious technical problem and the factors associated with it.

Free-Floating Right Heart Thrombus with Acute Massive Pulmonary Embolism: A Case Report and Review of the Literature

Free-floating right heart thrombus (RHT) is an extreme medical emergency in the context of acute massive pulmonary embolism (PE). Despite the advances in early diagnosis, the management is still very debatable due to lack of consensus. We reported the case of a 66-year-old male, with a history of moderate renal dysfunction and dilated cardiomyopathy, who presented to the emergency department for acute dyspnea. His angiographic magnetic resonance imaging revealed bilateral extensive PE. Transthoracic echocardiography showed RHT with moderate right ventricular dysfunction and pulmonary hypertension. Venous Doppler of the lower extremities noted the presence of a floating clot in the right common femoral vein. The patient was managed successfully by thrombolytic therapy with tenecteplase. To the best of our knowledge, this is the first case report of RHT and PE from Lebanon. Published cases from Middle Eastern countries are scarse.

Abstract P3-06-01: Not presented

This abstract was not presented at the symposium.

Peripartum cardiomyopathy, place of drug therapy, assist devices, and outcome after left ventricular assistance

Peripartum cardiomyopathy remains a challenging obstetric and cardiologic emergency. We report 5 interesting cases of peripartum cardiomyopathy with different clinical courses, with 3 patients requiring left ventricular assist device implantation. One patient underwent pump explantation and aortic balloon valvuloplasty postsurgery. Two patients improved with the medical treatment alone without the need of assistance. We will review main important related issues.

Cor Triatriatum Sinister diagnosed in adult life with three dimensional transesophageal echocardiography

Background

Cor triatriatum is a very rare congenital abnormality, usually symptomatic during childhood, diagnosis in adult age is less common.

Case Presentation

We report the case of a 40 years old woman referred to our hospital for atrial flutter ablation, transthoracic cardiac bidimensional echocardiography showed an abnormal membrane bisecting the left atrium, the diagnosis of cor triatriatum was fully made via three dimensional transesophageal echocardiography. More interstingly three other cardiac anomalies were associated: ostium secundum atrial septal defect, dilated coronary sinus due probably to persistent left superior vena cava and normally functioning bicuspid aortic valve.

Conclusions

Cor triatriatum sinister in adult life is important to recognize because it may be easily surgically correctable when hemodynamically significant. Three Dimensional transesophageal echocardiography is a minimally invasive and highly sensitive diagnostic modality.

Prolactin microinjections into the amygdalar central nucleus lead to decreased NREM sleep

Prolactin administered systemically, intracerebroventricularly or locally into the lateral hypothalamus enhances rapid eye movement sleep (REM) when given diurnally and decreases REM when given nocturnally. The amygdala is being recognized as an important modulator of behavioral state, and the central nucleus of the amygdala (CNA) has a high concentration of prolactin fibers and receptors. We microinjected prolactin (10, 100, 250 ng/0.2 microliter saline) or saline alone into CNA of rats and measured the effect on behavioral state. Prolactin produced a dose-dependent decrease in non-REM (NREM), with the effect becoming significant at the high (250 ng) dose. REM was not significantly affected at any dosage. The results indicate a role for prolactin in CNA in the control of NREM. The results are discussed in terms of the amygdala having a broad role in the regulation of behavioral state.