Management of anticoagulation in patients with infective endocarditis.

Infective endocarditis (IE) carries a high risk of vascular complications (e.g., cerebral embolism, intracerebral hemorrhage, and renal infarction), which are correlated with increased early and late mortality. Although anticoagulation is the cornerstone for management of thromboembolic complications, it remains controversial and challenging in patients with IE. An appropriate anticoagulation strategy is crucial to improving outcomes and requires a good understanding of the indication, timing, and regimen of anticoagulation in the setting of IE. Observational studies have shown that anticoagulant treatment failed to reduce the risk of ischemic stroke in patents with IE, supporting that IE alone is not an indication for anticoagulation. In the absence of randomized controlled trials and high-quality meta-analyses, however, current guidelines on IE were based largely on observational data and expert opinion, providing few specific recommendations on anticoagulation. A multidisciplinary approach and patient engagement are required to determine the timing and regimen of anticoagulation in patients with IE, especially in specific situations (e.g., receiving warfarin anticoagulation at the time of IE diagnosis, cerebral embolism or ischemic stroke, intracerebral hemorrhage, or urgent surgery). Collectively, individualized strategies on anticoagulation management of IE should be based on clinical evaluation, available evidence, and patient engagement, and ultimately be developed by the multidisciplinary team.

Anticoagulation in cardiomyopathy: unravelling the hidden threat and challenging the threat individually.

Cardiomyopathy comprises a heterogeneous group of myocardial abnormalities, structural or functional in nature, in the absence of coronary artery disease and other abnormal loading conditions. These myocardial pathologies can result in premature death or disability from progressive heart failure, arrhythmia, stroke, or other embolic events. The European Cardiomyopathy Registry reports a high stroke risk in cardiomyopathy patients ranging from 2.1% to 4.5%, as well as high prevalence of atrial fibrillation ranging from 14.0% to 48.5%. There is a growing interest in evaluating the risk of thromboembolism depending on the type of cardiomyopathy, as well as if anticoagulation is indicated in patients with cardiomyopathy without atrial fibrillation. Data available do not unequivocally support anticoagulation therapy in all of these patients; the management of these patients remains challenging. Many published reports pertaining to the risk of thromboembolism and consecutive treatment strategies mainly focus on single cardiomyopathy subtype. We summarize essential pathophysiological knowledge and review current literature associated with thromboembolism in various cardiomyopathy subtypes, providing recommendations for the diagnostic evaluation as well as clinical management strategies in this field. Certain cardiomyopathy subtypes require anticoagulation independent of atrial fibrillation or CHA2 DS2 -VASc score. Despite the scarcity of evidence regarding the choice of anticoagulation regimen (vitamin K antagonist vs. non-vitamin K oral anticoagulants) in cardiomyopathy, it is discussed and reviewed in this article. Each patient should receive a tailored strategy based on thorough clinical evaluation, published evidence, and clinical experience, due to the current recommendations mostly developed on small-sample studies or empirical evidence. The future research priorities in this area are also addressed in this article.

Challenges and strategies in the management of coronary artery aneurysms.

Coronary artery aneurysms (CAAs) are infrequent but not rare. Because of the lack of supportive data and a substantial knowledge gap in this field, clinicians are in a dilemma how to manage patients with coronary artery aneurysms. Most often, CAAs are discovered incidentally, while symptomatic patients present with diverse complications of unstable angina, myocardial infarction, arrhythmias, or sudden cardiac death. Therapeutical approaches consist of surgical procedure, percutaneous coronary intervention (PCI), and medical management. Because of the scarcity of randomized trials or large-scale data on symptomatic and asymptomatic patients with coronary artery aneurysms, the management of these patients poses considerable challenges for the cardiologists. This review summarizes the current literature, a proposed algorithm for the management of CAAs is highlighted in the text. In view of the majority of current proposal information based on small series of case reports or observational studies, an individualized therapeutic regimen should be on the basis of the location, expansion by time, morphology, complications, and etiologies of the coronary artery aneurysms, the clinical presentations, and the patient's characteristics.

Chest wall lymph node metastasis from follicular thyroid carcinoma: a rare case report.

BACKGROUND: Distant metastases from follicular thyroid carcinoma are mainly hematogenous and are commonly observed in the lungs and bones. Other rare sites are the parotid gland, skin, brain, ovary, adrenal gland, kidney, pancreas and breast, with chest wall lymph node metastasis being even more rare. CASE PRESENTATION: Over the past 10 years, three surgeries were performed on a 69-year-old women with a history of follicular thyroid cancer and its metastatic lesions. The patient presented with a 3-month history of masses in the left chest. She underwent detailed examination of the chest wall tumors, and surgery was then performed to resect all of the tumors. Based on the histopathology, these lymph nodes were confirmed to harbor metastatic follicular thyroid carcinoma. CONCLUSION: This study reports the first case of follicular thyroid carcinoma metastasis to the chest wall lymph node.