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Becher H, Alhumaid W, Windram J, Choy J. Contrast Echocardiography in Heart Failure: Update 2023. Curr Heart Fail Rep 2024; 21:63-72. [PMID: 38305851 DOI: 10.1007/s11897-024-00647-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
PURPOSE OF REVIEW The application of ultrasound-enhancing agents (contrast agents) has improved the accuracy and reproducibility of echocardiography. The review focuses on the currently approved and evolving indications for contrast echocardiography in patients with heart failure, specifically examining clinical studies conducted after the publication of the guidelines in 2017 and 2018. RECENT FINDINGS The current ASE/EACVI recommendations for contrast echocardiography are based on its accuracy and reproducibility in comparison to non-enhanced echocardiography or other imaging modalities like cardiac MRI. However, tissue characterization remains limited with contrast echocardiography. During the last few years, several studies have demonstrated the clinical impact of using contrast agents on the management of patients with heart failure. There is growing evidence on the benefit of using contrast echocardiography in critically ill patients where echocardiography without contrast agents is often suboptimal and other imaging methods are less feasible. There is no risk of worsening renal function after the administration of ultrasound-enhancing agents, and these agents can be administered even in patients with end-stage renal disease. Contrast echocardiography has become a valuable tool for first-line imaging of patients with heart failure across the spectrum of patients with chronic heart failure to critically ill patients.
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Affiliation(s)
- Harald Becher
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 0A8.32, 8440 112 Street Edmonton, Alberta, T6G 2B7, Canada.
| | - Waleed Alhumaid
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 0A8.32, 8440 112 Street Edmonton, Alberta, T6G 2B7, Canada
| | - Jonathan Windram
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 0A8.32, 8440 112 Street Edmonton, Alberta, T6G 2B7, Canada
| | - Jonathan Choy
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, 0A8.32, 8440 112 Street Edmonton, Alberta, T6G 2B7, Canada
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Shah N, Abu Orabi Z, Warfield AT, Steeds R, Patel PA. Persistent Prothrombotic State in a Patient With Alström Syndrome. JACC Case Rep 2024; 29:102215. [PMID: 38464801 PMCID: PMC10920103 DOI: 10.1016/j.jaccas.2023.102215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 03/12/2024]
Abstract
We present the case of a patient with Alström syndrome who was found to have evidence of a prothrombotic state on autopsy after sudden cardiac death. To the best of our knowledge, this case of persistent prothrombotic milieu is the first described in a patient with Alström syndrome.
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Affiliation(s)
- Nihit Shah
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Zeina Abu Orabi
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Adrian T. Warfield
- Department of Cellular Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Immunology & Immunotherapy, University of Birmingham, United Kingdom
| | - Richard Steeds
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Peysh A. Patel
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
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3
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Weberling LD, Seitz S, Salatzki J, Ochs A, Heins J, Haney AC, Siry D, Frey N, André F, Steen H. Safety of dobutamine or adenosine stress cardiac magnetic resonance imaging in patients with left ventricular thrombus. Clin Res Cardiol 2024; 113:446-455. [PMID: 37843560 PMCID: PMC10881726 DOI: 10.1007/s00392-023-02317-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Left ventricular (LV) thrombus formation is a common but potentially serious complication, typically occurring after myocardial infarction. Due to perceived high thromboembolic risk and lack of safety data, stress cardiac magnetic resonance (CMR) imaging especially with dobutamine is usually avoided despite its high diagnostic yield. This study aimed to investigate the characteristics, safety and outcome of patients with LV thrombus undergoing dobutamine or vasodilator stress CMR. METHODS Patients undergoing stress CMR with concomitant LV thrombus were retrospectively included. Risk factors, comorbidities, and previous embolic events were recorded. Periprocedural safety was assessed for up to 48 h following the examination. Major adverse cardiac events (MACE) 12 months before the diagnosis were compared to 12 months after the exam and between patients and a matched control group. Additionally, patients were followed up for all-cause mortality. RESULTS 95 patients (78 male, 65 ± 10.7 years) were included. Among them, 43 patients underwent dobutamine (36 high-dose, 7 low-dose) and 52 vasodilator stress CMR. Periprocedural safety was excellent with no adverse events. During a period of 24 months, 27 MACE (14.7%) occurred in patients and controls with no statistical difference between groups. During a median follow-up of 33.7 months (IQR 37.6 months), 6 deaths (6.3%) occurred. Type of stress agent, thrombus mobility, or protrusion were not correlated to embolic events or death. CONCLUSION The addition of a stress test to a CMR exam is safe and does increase the generally high cardioembolic event rate in LV thrombus patients. Therefore, it is useful to support reperfusion decision-making.
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Affiliation(s)
- Lukas D Weberling
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany.
| | | | - Janek Salatzki
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Andreas Ochs
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Jannick Heins
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Ailís C Haney
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Deborah Siry
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Florian André
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Henning Steen
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Sahlén AO, Jiang H, Lau YH, Cuenza L, Cader FA, Al-Omary M, Surunchupakorn P, Ho KH, Sung J, Lee D, Honda S, Tan Wei Chieh J, Yap J. Direct Oral Anticoagulation Versus Warfarin in Left Ventricular Thrombus: Pooled Analysis of Randomized Controlled Trials. J Clin Pharmacol 2023; 63:1101-1107. [PMID: 37139934 DOI: 10.1002/jcph.2267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/02/2023] [Indexed: 05/05/2023]
Abstract
Patients with impaired left ventricular (LV) function can develop LV thrombus, a potentially life-threatening condition due to risk of stroke and embolization. Conventional treatment with vitamin K antagonists (VKAs; e.g., warfarin) puts patients at risk of bleeding, and the use of direct oral anticoagulants (DOACs) appears promising, although data are scant. We searched the published English language literature for randomized controlled trials (RCTs) comparing DOACs with VKAs in LV thrombus. End points were failure to resolve, thromboembolic events (stroke, embolism), bleeding, or any adverse event (composite of thromboembolism or bleeding), or all-cause death. Data were pooled and analyzed in hierarchical Bayesian models. In three eligible RCTs, 141 patients were studied during an average of 4.6 months (53.8 patient-years; n = 71 assigned to DOAC, n = 70 assigned to VKA). A similar number of patients in each treatment arm demonstrated failure to resolve (DOAC: 14/71 vs. VKA: 15/70) and death events (3/71 vs. 4/70). However, patients on DOACs suffered fewer strokes/thromboembolic events (1/71 vs. 7/70; log odds ratio [OR], -2.02 [95% credible interval (CI95 ), -4.53 to -0.31]) and fewer bleeding events (2/71 vs. 9/70; log OR, -1.62 [CI95 , -3.43 to -0.26]), leading to fewer patients on DOACs with any adverse event versus VKAs (3/71 vs. 16/70; log OR, -1.93 [CI95 , -3.33 to -0.75]). In conclusion, pooled analysis of RCT data favors DOACs over VKAs in patients with LV thrombus in terms of both efficacy and safety.
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Affiliation(s)
- Anders Olof Sahlén
- National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Karolinska Institutet, Huddinge, Sweden
| | - Haowen Jiang
- Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Yee How Lau
- National Heart Centre Singapore, Singapore, Singapore
| | - Lucky Cuenza
- Philippines Heart Center, Quezon City, Philippines
| | - F Aaysha Cader
- Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh
| | | | | | - Ka Hei Ho
- Tuen Mun Hospital, Hong Kong, Hong Kong
| | | | - Derek Lee
- Queen Elizabeth Hospital, Hong Kong, Hong Kong
| | - Satoshi Honda
- National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Jack Tan Wei Chieh
- National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jonathan Yap
- National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Damughatla AR, Milan-Ortiz V, Koleti P, Milan-Ortiz MM, Pasham SR, Damughatla AR, Kamatham S, Bazzy K. Identifying the Cause of Acute Left-Sided Visual Loss: A Clinical Dilemma. J Med Cases 2023; 14:200-203. [PMID: 37435103 PMCID: PMC10332869 DOI: 10.14740/jmc4093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023] Open
Abstract
Given the global increase in the incidence of head and neck cancers over the last decade, the use of chemoradiation has also increased. It is well known that chemotherapy/radiation are established standard therapies in head and neck cancers, especially in patients who are not candidates for surgery. Despite this increase in chemoradiation therapies in head and neck cancers, there is a lack of established guidelines on the surveillance and screening of these patients for long-term complications. We present an interesting case of acute left eye blindness in a veteran patient with a history of laryngeal cancer status post chemoradiation and in the setting of a left ventricular (LV) thrombus on anticoagulation resulting in a diagnostic challenge determining the etiology. This case emphasizes the need for thorough patient-centered annual evaluation, thus providing an opportunity for early noninvasive or minimally invasive intervention.
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Affiliation(s)
- Anirudh R. Damughatla
- Department of Internal Medicine, Wayne State University & Detroit Medical Center, Detroit, MI, USA
- Department of Internal Medicine, John D. Dingell Veterans Affairs Medical Center, Detroit, MI, USA
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA
| | - Vanessa Milan-Ortiz
- Department of Internal Medicine, Wayne State University & Detroit Medical Center, Detroit, MI, USA
- Department of Internal Medicine, John D. Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Pragna Koleti
- Department of Internal Medicine, Suburban Community Hospital, Norristown, PA, USA
| | | | - Sudhir Reddy Pasham
- Department of Internal Medicine, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | | | - Saivaishnavi Kamatham
- Department of Internal Medicine, Wayne State University & Detroit Medical Center, Detroit, MI, USA
- Department of Internal Medicine, John D. Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Kareem Bazzy
- Department of Internal Medicine, Wayne State University & Detroit Medical Center, Detroit, MI, USA
- Department of Internal Medicine, John D. Dingell Veterans Affairs Medical Center, Detroit, MI, USA
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Honan KA, Jogimahanti A, Khair T. An Updated Review of the Efficacy and Safety of Direct Oral Anticoagulants in Treatment of Left Ventricular Thrombus. Am J Med 2022; 135:17-23. [PMID: 34469758 DOI: 10.1016/j.amjmed.2021.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022]
Abstract
Left ventricular (LV) thrombus is a potentially serious complication affecting males and females with ischemic and nonischemic cardiomyopathy-specifically, after acute myocardial infarctions of the anterior left ventricular wall and long-standing tachyarrhythmias, respectively. LV thrombi pose significant risks for systemic embolization and devastating stroke events, while also demanding a treatment carrying inherent risks of its own. It is therefore imperative to have accurate detection of these ventricular thrombi and an appropriate understanding of the risks and benefits regarding management. Anticoagulation using warfarin has long been established as the gold-standard level of care in the current guidelines of the American College of Cardiology but the advent of direct oral anticoagulants (DOACs) prompts a re-examination of the literature. The particular question we seek to answer lies in the efficacy of these drugs and the safety and outcomes when used to treat LV thrombi. Recent case reports, meta-analyses, and most recently, the breakthrough of 2 novel randomized controlled trials have shown DOACs to be a promising treatment for LV thrombus. Contrarily, some retrospective cohort reviews suggest less-than-promising outcomes. This meta-analysis hopes to provide a current, curated review of up-to-date safety and efficacy in the documented tales of DOACs and LV thrombi that has been published since early 2020-by selecting these curated case studies, and analyzing the most recent randomized controlled trials, we hope to engage the reader with clearer illustrations of the key components of both the advocacy and warning of this pharmaceutical intervention.
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Affiliation(s)
- Kevin A Honan
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston.
| | - Arjun Jogimahanti
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston
| | - Tarif Khair
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston
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Trongtorsak A, Thangjui S, Kewcharoen J, Polpichai N, Yodsuwan R, Kittipibul V, Friedman HJ, Estrada AQ. Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis. Acta Cardiol 2021; 76:933-942. [PMID: 33393861 DOI: 10.1080/00015385.2020.1858538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Current guidelines recommend vitamin K antagonists (VKAs) to reduce the risk of systemic thromboembolic (STE) events in patients with left ventricular (LV) thrombus. Direct oral anticoagulants (DOACs) are an emerging alternative to VKAs; however, data supporting DOAC use in LV thrombus are still lacking. We conducted this systematic review and meta-analysis to compare the efficacy and safety between DOACs and VKAs in this population. METHODS We searched MEDLINE, Embase, and the Cochrane Library databases from inception to October 2020 to identify studies that compared clinical outcomes of interest, including stroke or any STE, LV thrombus resolution, and bleeding, between patients who used DOACs and VKAs for LV thrombus. Data from each study were combined using the random-effects model. RESULTS Eight cohort studies with a total of 1771 patients (426 in DOAC group, 1345 in VKA group) were included. There were no statistically significant differences between VKA group and DOAC group on rates of STE events (pooled RR = 1.12, 95% confidence interval [CI]: 0.91-1.39, p = .286), LV thrombus resolution (pooled RR = 1.09, 95% CI: 0.94-1.27, p = .242), or bleeding events (pooled RR = 0.94, 95% CI: 0.59-1.51, p = .808). CONCLUSIONS Our meta-analysis found no significant differences in rates of STE events, LV thrombus resolution, or bleeding events between the use of DOACs and VKAs in LV thrombus. Further randomised controlled trials are needed to confirm our findingsHighlightsThere is limited evidence comparing the use of direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in left ventricular (LV) thrombus.Our systematic review and meta-analysis showed that DOACs are not inferior to VKAs in the incidence of systemic thromboembolism (STE), the rate of LV thrombus resolution, and the risk of bleeding.Current evidence is based on observational studies only. Further randomised controlled trials are needed to confirm the findings.
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Affiliation(s)
- Angkawipa Trongtorsak
- Internal Medicine Residency Program, Amita Health Saint Francis Hospital, Evanston, IL, USA
| | - Sittinun Thangjui
- Internal Medicine Residency Program, Bassett Medical Center, Cooperstown, NY, USA
| | - Jakrin Kewcharoen
- Internal Medicine Residency Program, University of Hawaii, Honolulu, HI, USA
| | - Natchaya Polpichai
- Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand
| | - Ratdanai Yodsuwan
- Internal Medicine Residency Program, Bassett Medical Center, Cooperstown, NY, USA
| | | | - Harvey J. Friedman
- Department of Pulmonary Medicine and Critical Care, Amita Health Saint Francis Hospital, Evanston, IL, USA
| | - Alfonso Q. Estrada
- Department of Cardiovascular Medicine, Amita Health Saint Francis Hospital, Evanston, IL, USA
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Masood Noori MA, Saeed H, Rushdy A, Elkattawy S, Jawed Q, Guragai N, Shamoon F. Heart broken. An unusual case of biventricular takotsubo cardiomyopathy complicated by STEMI and Left ventricular thrombi. A case report. J Community Hosp Intern Med Perspect 2021; 11:703-707. [PMID: 34567469 PMCID: PMC8462894 DOI: 10.1080/20009666.2021.1942671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Takotsubo cardiomyopathy (TCM) is a rare occurrence in patients with troponin-positive acute coronary syndrome (ACS). It usually manifests as transient apical ballooning of the left ventricle with concomitant occurrence of right ventricular involvement in only one-third of cases. Biventricular TCM is associated with more hemodynamic instability as compared to left sided alone. Depressed ventricular systolic function and localized ventricular dyskinesis can facilitate clot formation in ventricular cavity. We present a case of 80-year-old man who presented to the ED for evaluation of hypotension. An electrocardiogram suggested acute anterior wall myocardial infarction. He underwent emergent coronary angiography and was found to have mid to apical akinesis and basal hyperkinesis with normal left coronaries and chronic total right coronary artery occlusion with excellent collaterals from left. A transthoracic echocardiography (TTE) revealed left ventricular ejection fraction 25–30% and akinesis of left and right ventricle except in the basal region. TTE with definity showed sessile thrombus. In our patient, sepsis was the most important triggering factor given initial presentation of hypotension with leukocytosis. Broad spectrum antibiotics including vancomycin and Zosyn were started considering a combination of septic and cardiogenic shock. Repeat EKG showed resolution of ST-T segment elevation but our patient remained hemodynamically unstable even with two pressure support and, ultimately, died 72 hours after admission. Herein, we emphasize on the importance right ventricular involvement and its relation to hemodynamic instability. This case highlights the importance of anticipating hemodynamic instability and clot formation in patients with biventricular Takotsubo cardiomyopathy.
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Affiliation(s)
| | - Hasham Saeed
- Department of Medicine, Rutgers New Jersey Medical School, Elizabeth, NJ, USA
| | - Abanoub Rushdy
- Department of Cardiology, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Sherif Elkattawy
- Department of Medicine, Rutgers New Jersey Medical School, Elizabeth, NJ, USA
| | - Qirat Jawed
- Department of Medicine, Rutgers New Jersey Medical School, Elizabeth, NJ, USA
| | - Nirmal Guragai
- Department of Cardiology, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Fayez Shamoon
- Department of Cardiology, St. Joseph's University Medical Center, Paterson, NJ, USA
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9
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Chan KH, Ramahi A, Lim SL, Ahmed E, Suleiman A, Slim J, Shaaban HS. Left ventricular thrombus complicated by acute limb ischemia in a patient with HIV. Radiol Case Rep 2021; 16:2416-2420. [PMID: 34257771 PMCID: PMC8260751 DOI: 10.1016/j.radcr.2021.05.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 12/01/2022] Open
Abstract
Left ventricular thrombus typically occurs in patients with impaired left ventricular function such as aneurysm, dilated cardiomyopathy, or post-myocardial infarction. Untreated HIV infection is known to increase the risk of venous thromboembolism and cardiovascular disease. However, the pathophysiology remains uncertain; some studies have proposed chronic inflammation as the underlying etiology. Nonetheless, left ventricular thrombus is extremely rare among persons living with HIV with no known underlying cardiac disease. Herein, we report an unusual case of a 55-year-old homeless and heterosexual male with past medical history of HIV, who has mildly reduced left ventricular function and a nonmobile, medium size left ventricular thrombus. Patient was initially treated with therapeutic dose of enoxaparin, and subsequently developed acute embolic occlusion of right femoral artery that lead to an above knee amputation. To our knowledge, left ventricular thromboembolism complicated with acute embolic ischemia in persons living with HIV is extremely rare. The presenting case will definitely add to the current body of knowledge and will raise awareness among physicians, in recognizing the rare association between HIV and arterial thromboembolism.
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Affiliation(s)
- Kok Hoe Chan
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Amr Ramahi
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Su Lin Lim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Eyad Ahmed
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Addi Suleiman
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Cardiology, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Jihad Slim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Infectious Disease, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Hamid S Shaaban
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Hematology/Oncology, Saint Michael's Medical Centre, New York Medical College, NJ, USA
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10
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Bass ME, Kiser TH, Page RL, McIlvennan CK, Allen LA, Wright G, Shakowski C. Comparative effectiveness of direct oral anticoagulants and warfarin for the treatment of left ventricular thrombus. J Thromb Thrombolysis 2021; 52:517-522. [PMID: 33420896 DOI: 10.1007/s11239-020-02371-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/05/2023]
Abstract
Left ventricular (LV) thrombus is a complication of acute endomyocardial injury and chronic ventricular wall hypokinesis, resulting in increased risk of thromboembolic complications. Observational studies support the general safety and efficacy of warfarin for this indication. Limited data exists regarding the use of direct oral anticoagulants (DOACs) for LV thrombus. This retrospective cohort study sought to compare the incidence of thromboembolic events, bleeding rates, and blood product administration in patients receiving a DOAC versus warfarin. A total of 949 patients met inclusion, 180 (19%) received a DOAC and 769 (81%) warfarin. For the primary endpoint of new onset thromboembolic stroke, no difference existed between treatments (DOAC: 7.8% vs warfarin: 11.7%, p = 0.13). When compared to warfarin, no difference existed in the composite of thromboembolic events (33% vs 30.6%, p = 0.53, respectively) or in GUSTO bleeding (10.9% vs 7.8%, p = 0.40, respectively). More patients on warfarin received blood products compared to those taking a DOAC (25.8% vs 13.9%, p < 0.001).DOACs may be an alternative to warfarin for the treatment of LV thrombus based on a retrospective assessment of thromboembolic events and GUSTO bleeding events within 90 days of diagnosis of LV thrombus. However, further prospective studies are warranted.
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Affiliation(s)
- Megan E Bass
- Department of Pharmacy, UCHealth - University of Colorado Hospital, 12505 E. 16th Avenue, Aurora, CO, 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Robert L Page
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Colleen K McIlvennan
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Larry A Allen
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Garth Wright
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Courtney Shakowski
- Department of Pharmacy, UCHealth - University of Colorado Hospital, 12505 E. 16th Avenue, Aurora, CO, 80045, USA.
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11
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El-Battrawy I, Behnes M, Hillenbrand D, Haghi D, Hoffmann U, Papavassiliu T, Lang S, Fastner C, Becher T, Baumann S, Heggemann F, Kuschyk J, Borggrefe M, Akin I. Prevalence, Clinical Characteristics, and Predictors of Patients with Thromboembolic Events in Takotsubo Cardiomyopathy. Clin Med Insights Cardiol 2016; 10:117-22. [PMID: 27429563 PMCID: PMC4944829 DOI: 10.4137/cmc.s38151] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 03/28/2016] [Accepted: 03/29/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Several acute complications related to takotsubo cardiomyopathy (TTC) have been documented recently. However, the incidence and clinical significance of acute thromboembolic events in TTC is not well established. METHODS A detailed investigation of the clinical characteristics and in-hospital complications of 114 consecutive patients diagnosed with TTC between January 2003 and September 2015 was carried out. This study was initiated to reveal the predictors, clinical significance, and short-term and long-term outcomes of patients with TTC associated with acute thromboembolic events on index presentation. RESULTS The incidence of acute thromboembolic events related to TTC was around 12.2%, and these included ventricular thrombi, cerebrovascular events, retinal and brachial artery pathologies, renal, splenic, and aortic involvement. The most frequent complication on initial presentation was cardiogenic shock (20%) accompanied with pulmonary congestion (20%). Interestingly, patients experiencing thromboembolic events had higher C-reactive protein (CRP) levels as compared to the non-thromboembolic group (P = 0.02). Certain thromboembolic events were characterized by the presence of ST-segment elevation in electrocardiogram (P = 0.02). Chest pain was the primary symptom in these patients (P = 0.09). Furthermore, there was significant right ventricular involvement (as assessed by transthoracic echocardiography) in patients presenting with an acute thromboembolic event (P = 0.08). A Kaplan–Meier analysis indicated a significantly higher mortality rate over a mean follow-up of three years in the thromboembolic group than the non-thromboembolic group (log-rank, P = 0.02). CONCLUSIONS Our results confirmed the relative common occurrence of thromboembolic events in the setting of TTC. Inflammation might play an important role in the development of thromboembolic events, and a right ventricular involvement and ST-segment elevation could be positive predictors for this occurrence. In order to circumvent the risk of a negative outcome, it is recommended that an anticoagulation therapy be initiated in all high-risk patients.
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Affiliation(s)
- Ibrahim El-Battrawy
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg-Mannheim, Mannheim, Germany
| | - Michael Behnes
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg-Mannheim, Mannheim, Germany
| | - Dennis Hillenbrand
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Darius Haghi
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Theano Papavassiliu
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg-Mannheim, Mannheim, Germany
| | - Siegfried Lang
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg-Mannheim, Mannheim, Germany
| | - Christian Fastner
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Tobias Becher
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan Baumann
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Felix Heggemann
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jürgen Kuschyk
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg-Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg-Mannheim, Mannheim, Germany
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Potu C, Tulloch-Reid E, Baugh D, Madu E. Left ventricular thrombus in patients with acute myocardial infarction:Case report and Caribbean focused update. Australas Med J 2012; 5:178-83. [PMID: 22952564 DOI: 10.4066/amj.20121103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Despite the well documented benefit of echocardiography in acute coronary syndromes, its wide-scale use in the Caribbean is limited by access, health literacy and affordability. Because of the limited use of echocardiography in the region, routine complications of acute myocardial infarction (AMI) are not fully appreciated and may go unrecognized, further contributing to increased cardiovascular morbidity and mortality. It is therefore necessary to bring focus to this common clinical condition and highlight the clinical utility of echocardiography in facilitating timely and accurate diagnosis. We report here a case of large left ventricular (LV) thrombus in a patient with AMI. Coronary angiography showed completely occluded left anterior descending artery (LAD) with angiographically normal remaining vessels. Immediate anticoagulation was commenced with heparin and overlapped with warfarin. No Primary Angioplasty (PA) was done based on the evidence from occluded artery trial. LV thrombus was completely resolved on echocardiography at three months. No evidence of thrombo-embolism was found during the resolution of LV thrombus.
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Affiliation(s)
- Cr Potu
- Department of Medicine, Division of Cardiovascular Medicine, Heart Institute of the Caribbean, Kingston, Jamaica
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13
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Aziz F, Doddi S, Kallu S, Penupolu S, Alok A. Myocardial Infarction (MI) presenting as acute limb: an extremely rare presentation of MI. J Thorac Dis 2010; 2:57-59. [PMID: 22263019 PMCID: PMC3256437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 02/25/2010] [Indexed: 05/31/2023]
Abstract
Acute embolic occlusion of the bilateral lower limbs from the left ventricular thrombus is an extremely rare medical condition that is not only limb threatening but also potentially life threatening. Several strategies are available but not even a single treatment modality is clearly the best. Here, we present an interesting case that presented with bilateral lower limb ischemia and was later found to have a big thrombus in the left ventricle as the source of the emboli.
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Affiliation(s)
- Fahad Aziz
- Jersey City Medical Center, Jersey City, NJ, USA
| | | | - Swapna Kallu
- Jersey City Medical Center, Jersey City, NJ, USA
| | | | - Anshu Alok
- Jersey City Medical Center, Jersey City, NJ, USA
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