Intracardiac thrombosis after congenital heart disease surgeries in neonates: a report of two cases.

BACKGROUND: Intracardiac thrombosis (ICT) is a rare complication after the cardiopulmonary surgery for interrupted aortic arch (IAA) or total anomalous pulmonary venous connection (TAPVC) without previous records. There are still no general guidelines regarding as the mechanism or management of postoperative ICT in neonates and younger infants. CASE PRESENTATION: We reported the conservative and surgical therapies in two neonates with intra-ventricular and intra-atrial thrombosis after the anatomical repair for IAA and TAPVC, respectively. There were no risk factors for ICT in both patients, except for the use of blood product and prothrombin complex concentrate. The surgery was indicated after TAPVC correction due to the worsening respiratory status and rapidly decreased mixed venous saturation. Anticoagulation combined with antiplatelet therapies was adopted in another patient. These two were both finally recovered, and three-month, six-month, and one-year follow-up echocardiography revealed no abnormality. CONCLUSIONS: ICT is uncommon in pediatric population after the surgery for congenital heart disease. Single ventricle palliation, heart transplantation, longer central line use, post-extracorporeal membrane oxygenation, and massive blood product use are major risk factors for postcardiotomy thrombosis. The causes of postoperative ICT are multifactorial, and the immaturity of thrombolytic and fibrinolytic system in neonates may serve as a prothrombotic factor. However, no consensus reached regarding as the therapies for postoperative ICT, and the large-scale prospective cohort study or randomized clinical trial is needed.

A rare complication of Behçet's disease in a 12-year-old girl: a large intracardiac thrombosis.

Behcet's disease is a multi-systemic inflammatory disease with a clinical spectrum as a triple complex of recurrent oral, genital ulcers, and uveitis. Cardiac involvement in patients with Behcet's disease is extremely rare and often associated with poor prognosis. Behcet's disease should be considered in the differential diagnosis of right ventricular mass especially in young adults, even there is no typical clinical features of Behcet's disease. In this case, a 12-year-old girl who admitted with chest pain and haemoptysis and then was diagnosed with intracardiac thrombus related to Behcet's disease during follow-up was described.

Fatal Pulmonary Hemorrhagic Infarction Caused by Pulmonary Vein Thrombotic Occlusion During Venoarterial Extracorporeal Membrane Oxygenation.

A 20-year-old man with arrhythmogenic right ventricular cardiomyopathy (ARVC) was resuscitated from ventricular fibrillation. He was transferred to our hospital because of progressive multiorgan dysfunction despite mechanical circulatory support with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP). At admission to our hospital, chest X-ray showed bilateral complete lung opacification, and echocardiography revealed a massive thrombus occupying the left atrium (LA) and left ventricle (LV). Conversion to central ECMO with transapical LV venting and thrombectomy were performed. The huge LA thrombus occluded all pulmonary veins (PVs). Despite the surgery and intensive care, complete lung opacity remained, and he died of multiorgan failure associated with sepsis. Autopsy demonstrated bilateral pulmonary multiple red infarctions, and histopathology showed alveolar wall necrosis with extensive hemorrhage, confirming a diagnosis of pulmonary hemorrhagic infarction. Extensive pulmonary infarction was attributable to PV occlusion due to massive LA thrombus. PV thrombosis should be considered when refractory lung opacities are encountered during VA-ECMO and necessitates early intervention.

[Clinical characteristics of cardiomyopathies complicated with ventricular thrombosis].

Objective: To summarize the clinical characteristics of cardiomyopathy complicated with ventricular thrombosis. Methods: The clinical data of inpatients suffered from cardiomyopathy complicated with ventricular thrombosis in Fuwai Hospital between January 2015 and May 2019 were analyzed retrospectively. Results: A total of 125 cases were reviewed, and 24.8% were female. Dilated cardiomyopathy was the most common disease (62.4%), followed by arrhythmogenic right ventricular cardiomyopathy (ARVC) (13.6%) and hypertrophic cardiomyopathy (11.2%). There were 74.4% thrombosis in left ventricle, 12.8% in right ventricle and 12.8% in biventricle. The proportions of right ventricle thrombosis were higher in ARVC than in other cardiomyopathies (52.9% vs 6.5%, P<0.01). The majority suffered from cardiac function New York Heart Association (NYHA) Class Ⅲ (45.6%) and class Ⅳ (39.2%). The ratio of NYHA Class Ⅳ was higher in female patients than in male ones (25.8% vs 10.6%, P<0.05). In lab detection, positive results of D-Dimer and N terminal-pro B type natriuretic peptide (NT-proBNP) accounted for 72.8% and 97.6%, respectively. There were 2.5% patients died in the hospital or discharged because of the worsening of illness, the chances were higher in female than male patients (9.7% vs 0, P<0.01). Among these patients, one succumbed to massive ischemic stroke caused by ventricular thrombus detachment under standard anticoagulation therapy. Conclusions: Dilated cardiomyopathy is the most common cardiomyopathy complicated with ventricular thrombosis. The most common location of thrombosis is left ventricle. Right ventricle thrombosis is more common in ARVC. The majority suffer from moderate or severe cardiac dysfunction. Higer proportion of female patients suffer from anemia, severe condition and poor prognosis.

Thrombotic and hemorrhagic complications during visceral transplantation: risk factors, and association with intraoperative disseminated intravascular coagulation-like thromboelastographic qualities: a single-center retrospective study.

This study describes the risk of thrombotic and hemorrhagic complications, both intraoperatively, and up to 1 month following visceral transplantation. Data from 48 adult visceral transplants performed between 2010 and 2017 were retrospectively studied [32 multivisceral (MVTx); 10 isolated intestine; six modified-MVTx]. Intraoperatively, intracardiac thrombosis (ICT)/pulmonary embolism (PE) occurred in 25%, 0% and 0% of MVTx, isolated intestine and modified MVTx, respectively, and was associated with 50% (4/8) mortality. Preoperative portal vein thrombosis (PVT) was a significant risk factor for ICT/PE (P = 0.0073). Thromboelastography resembling disseminated intravascular coagulation (DIC) (r time <4 mm combined with fibrinolysis or flat-line) was statistically associated with occurrence of ICT/PE (P < 0.0001). Compared to subgroup without ICT/PE, occurrence of ICT/PE was associated with an increased demand for all blood product components both overall, and each surgical stage. Hyperfibrinolysis (56%) was identified as cause of bleeding in MVTx. Incidence of postoperative thrombotic event at 1 month was 25%, 30% and 17% for MVTx, isolated intestine and modified MVTx, respectively. Incidence of postoperative bleeding complications at 1 month was 11%, 20% and 17% for MVTx, isolated intestine and modified MVTx. In conclusion, MVTx recipients with preoperative PVT are at an increased risk of developing intraoperative life-threatening ICT/PE events associated with DIC-like coagulopathy.

Non-vitamin K antagonist oral anticoagulants for the treatment of intracardiac thrombosis.

Intracardiac thrombus most commonly develops in the left atrial appendage (LAA) and left ventricle (LV) in the setting of atrial fibrillation (AF) and post-myocardial fibrillation (MI), respectively. Current guidelines recommend that patients with post-MI LV or LAA thrombus should be treated with vitamin K antagonist (VKA). However, the use of VKA may be limited by bleeding complications, interactions with various food and drugs, and a narrow therapeutic window requiring frequent monitoring. Thus, non-VKA oral anticoagulants (NOACs) have been attempted as an off-label use for the treatment of intracardiac thrombosis in light of their favorable pharmacologic profile. Until now, therapeutic effect of NOACs on intracardiac thrombosis has not been formally studied in large randomized controlled trials. This article aims to systematically review the literature regarding efficacy and safety outcome of NOACs in the management of intracardiac thrombus. Considering the high rate of complete thrombus resolution and low rate of thromboembolic or hemorrhagic complications, preliminary evidence from case series and reports indicate that NOACs (including factor Xa inhibitors and direct thrombin inhibitors) may be a safe and effective therapeutic option for intracardiac thrombosis, particularly in cases resistant to VKA therapy.

[Behçet's disease: Intracardiac thrombosis (a description of two cases and a review of literature)]. / Bolezn' Bekhcheta: vnutriserdechnyi tromboz (opisanie dvukh nabliudenii i obzor literatury).

Behçet's disease (BD) is systemic vasculitis of unknown etiology, which is more common in the countries located along the Great Silk Road. The disease is diagnosed if a patient has 4 key diagnostic signs: aphthous stomatitis, genital sores, and eye and skin lesions. Vascular diseases referred to as minor criteria for BD are characterized by the formation of aneurysms and thrombosis, predominantly in the venous bed. In venous disorders, a blood clot can form in any vessel, including caval, cerebral, pulmonary, and other veins. The paper describes two clinical cases of BD with intracardiac thrombosis. In one case, a 24-year-old male patient with a documented diagnosis of BD, echocardiography revealed a left ventricular spontaneous echo contrast phenomenon that disappeared due to immunosuppressive therapy. The other case was a 34-year-old female patient, in whom the diagnosis was based on the international disease criteria: aphthous stomatitis, skin lesions (pseudopustulosis, erythema nodosum), and genital sores. Computed tomographic angiography showed a 3.7×2.2-cm mass (thrombus) in the right atrium. In addition, blood clots were present in the hepatic and inferior vena cava. No abnormalities in the coagulation system were found in both cases.

Epsilon-Aminocaproic Acid Has No Association With Thromboembolic Complications, Renal Failure, or Mortality After Liver Transplantation.

OBJECTIVES: To examine the role of epsilon-aminocaproic acid (EACA) administered after reperfusion of the donor liver in the incidences of thromboembolic events and acute kidney injury within 30 days after orthotopic liver transplantation. One-year survival rates between the EACA-treated and EACA-nontreated groups also were examined. DESIGN: Retrospective, observational, cohort study design. SETTING: Single-center, university hospital. PARTICIPANTS: The study included 708 adult liver transplantations performed from 2008 to 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: EACA administration was not associated with incidences of intracardiac thrombosis/pulmonary embolism (1.3%) or intraoperative death (0.6%). Logistic regression (n = 708) revealed 2 independent risk factors associated with myocardial ischemia (age and pre-transplant vasopressor use) and 8 risk factors associated with the need for post-transplant dialysis (age, female sex, redo orthotopic liver transplantation, preoperative sodium level, pre-transplant acute kidney injury or dialysis, platelet transfusion, and re-exploration within the first week after transplant); EACA was not identified as a risk factor for either outcome. One-year survival rates were similar between groups: 92% in EACA-treated group versus 93% in the EACA-nontreated group. CONCLUSIONS: The antifibrinolytic, EACA, was not associated with an increased incidence of thromboembolic complications or postoperative acute kidney injury, and it did not alter 1-year survival after liver transplantation.

Intracardiac Thrombus in COVID-19 Inpatients: A Nationwide Study of Incidence, Predictors, and Outcomes.

COronaVIrus Disease-2019 (COVID-19) is associated with a hypercoagulable state. Intracardiac thrombosis is a potentially serious complication but has seldom been evaluated in COVID-19 patients. We assessed the incidence, associated factors, and outcomes of COVID-19 patients with intracardiac thrombosis. In 2020, COVID-19 inpatients were identified from the National Inpatient Sample (NIS) database. Data on clinical characteristics, intracardiac thrombosis, and adverse outcomes were collected. Multivariable logistic regression was used to identify factors associated with intracardiac thrombosis, in-hospital mortality, and morbidities. In 2020, 1,683,785 COVID-19 inpatients (mean age 63.8 years, 32.2% females) were studied. Intracardiac thrombosis occurred in 0.10% (1830) of cases. In-hospital outcomes included 13.2% all-cause mortality, 3.5% cardiovascular mortality, 2.6% cardiac arrest, 4.4% acute coronary syndrome (ACS), 16.1% heart failure, 1.3% stroke, and 28.3% acute kidney injury (AKI). Key factors for intracardiac thrombosis were congestive heart failure history and coagulopathy. Intracardiac thrombosis independently linked to higher risks of all-cause mortality (odds ratio [OR]: 3.32 (2.42-4.54)), cardiovascular mortality (OR: 2.95 (1.96-4.44)), cardiac arrest (OR: 2.04 (1.22-3.43)), ACS (OR: 1.62 (1.17-2.22)), stroke (OR: 3.10 (2.11-4.56)), and AKI (OR: 2.13 (1.68-2.69)), but not heart failure. While rare, intracardiac thrombosis in COVID-19 patients independently raised in-hospital mortality and morbidity risks.

Pacing lead thrombus in patient with recent COVID-19 infection and subsequent vaccination: a case report.

Background: The association between acute coronavirus disease-19 (COVID-19) infection and a hypercoagulable state has been exhaustively described throughout the pandemic. The presence of external devices, such as intracardiac leads, could predispose to higher thrombotic risk in this setting. We present a clinical case of intracardiac thrombosis on right ventricle device that occurred after COVID-19 infection and subsequent vaccination. Case summary: A 56-year-old man, suffering from usual interstitial pneumonia-pattern fibrosis, was admitted to our hospital because of worsening of his clinical status. About 10 days earlier, he had got vaccinated for COVID-19. Three months earlier, the patient had been reported to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection. A chest computed tomography scan showed thrombus partially occluding the left pulmonary artery. A transthoracic echocardiography and later a transoesophageal echocardiogram showed a mass adhered to the lead in the right ventricle, compatible with thrombosis, confirmed on a cardiac computed tomography scan. Blood tests showed no major changes except for a slight increase in D-dimer and fibrinogen. Therefore, the subject was treated with anticoagulants. Discussion: COVID-19 infection results in a hypercoagulable state with risk of developing thrombus diffusely, including intracardiac thrombosis. The presence of external devices, such as the intracardiac leads, may increase thrombotic risk since the presence of an external device in the bloodstream could trigger coagulation cascade. This case report highlights the need for special care in this patient setting, using specific imaging techniques for early and rapid diagnosis to optimize therapy.

Intracardiac thrombosis following intravenous zoledronate treatment in a child with steroid-induced osteoporosis.

OBJECTIVES: Bisphosphonates are used in childhood osteoporosis but can cause an acute phase reaction (APR) and hypocalcemia. We present a child with cardiac thrombosis following zoledronate, a previously unreported complication. CASE PRESENTATION: An 11-year-old with Duchenne muscular dystrophy and steroid-induced osteoporosis presented 48 h after first zoledronate infusion with fever, tachycardia, tachypnoea and hypoglycaemia. This was managed as acute adrenal crisis and possible sepsis. He also had hypocalcemia, hypophosphatemia, hyponatraemia and hypokalaemia. Echocardiography performed due to persistent chest pain and tachycardia revealed a left ventricular thrombus. CONCLUSIONS: Potential causes for intracardiac thrombosis in this patient include ventricular dysfunction due to acute adrenal crisis or electrolyte disturbance, and hypercoagulability due to the APR. Echocardiography should be considered in children with acute cardiovascular compromise following zoledronate. Stress-dose steroids to cover the APR and a reduced starting dose of zoledronate might have reduced the risk of this complication.

Secondary right atrial thrombosis in three dogs: Antithrombotics therapy and echocardiographic follow-up.

Three dogs were diagnosed with right atrial thrombosis, thought to be secondary to systemic diseases. Specifically, two cases had hyperadrenocorticism and one case was diagnosed with pancreatitis with acute renal injury. In all cases, the thrombi were found within the right atrium, necessitating a differentiation from cardiac neoplasia. In all three cases, the structures assumed to be thrombi had irregular margins with interspersed hypoechoic regions, which were later confirmed as thrombi based on the responsiveness to therapy. All three cases were prescribed with the combination of clopidogrel and rivaroxaban.The thrombi gradually disappeared after initiation of the combination therapy. Complete resolution of right atrial thrombosis was noted in each dog treated with clopidogrel and rivaroxaban. This combination therapy appears to be safe and well tolerated. Diligent observation of the echocardiographic findings and clinical course allows the diagnosis of thrombosis.

Anasarca Revealing Severe Cardiac Involvement Due to Behçet's Disease (BD): A Case Report.

Behçet's disease (BD) is a systemic vasculitis which is most often manifested by recurrent oral aphthosis, genital aphthosis, and ocular involvement with sometimes visceral damage, in particular neurological, digestive, vascular, or renal. We report the case of a 21-year-old man admitted for anasarca who revealed severe cardiac involvement associating endomyocardial fibrosis, intracardiac thrombi and involvement of the tricuspid valve in the context of BD diagnosed a posteriori. Cardiac involvement is exceptional during BD, especially as a mode of entry into the disease. It can be particularly severe, hence the need for early diagnosis, rapid and sometimes aggressive management. Close monitoring is also necessary in order to watch for the occurrence of visceral manifestations, particularly in young patients.

Cavitary lung opacity of unusual cause during Behçet disease.

Pulmonary artery aneurysm must be evoked in front of any hemoptysis in a patient with Behçet disease as it requires urgent immunosuppressive therapy and often surgery.

A Case of Right Ventricular Thrombus in a Patient With Recent COVID-19 Infection.

Coronavirus disease 2019 (COVID-19) is a viral respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The respiratory system is the main target of the virus; however, apart from lung disease, a relatively large proportion of patients develop thrombosis as well. We present the case of a 19-year-old male who was admitted after contracting community-acquired right-sided pneumonia. The patient had a history of COVID-19 infection four weeks before admission. The echocardiographic assessment revealed a 16 x 6-mm right ventricular (RV) thrombus. He underwent a cardiovascular magnetic resonance (CMR) study, which confirmed the findings. After ruling out the most common causes of hypercoagulability, COVID-19 was judged to be the cause of the thrombus. The patient was treated with warfarin. Follow-up imaging with echocardiography and CMR six months later revealed complete resolution of the thrombus. Hypercoagulability is a major complication of COVID-19 and in situ thrombosis can occur both in the arterial and venous circulation. The recognition of intracardiac thrombi even in low-risk patients with a history of COVID-19 infection and the immediate initiation of antithrombotic treatment to minimize the risk of embolization is of paramount importance. Advanced imaging techniques are often required to establish the diagnosis of this condition.

A Case Report of Venoarterial ECMO as Salvage Therapy for Prolonged Cardiac Arrest Following Post-Reperfusion Intracardiac Thrombosis During Orthotopic Liver Transplantation.

In this report we describe the use of intraoperative venoarterial ECMO as salvage therapy in a unique case of post-reperfusion intracardiac thrombosis during liver transplantation with prolonged ACLS and coagulopathy. The limited literature on intraoperative ECMO as salvage therapy in liver transplantation is reviewed.

Unraveling the Association Between Myocardial Infarction of Nonobstructive Coronary Arteries and Antiphospholipid Syndrome.

The term "myocardial infarction with nonobstructive coronary arteries (MINOCA)" refers to a condition characterized by clinical signs and symptoms consistent with acute myocardial infarction (AMI) (as defined by the third universal definition of infarction) and coronary arteries that are angiographically normal or nearly normal. A prominent source of morbidity and mortality in patients with antiphospholipid syndrome (APS) is thrombotic events. To evaluate whether there is a relation between APS and MINOCA in this research, we did an extensive assessment of the existing research in this field. According to the data, APS was associated with microvascular thrombosis, aberrant lipid metabolism, hypertension, and abnormalities of the coagulation cascade, among other conditions. Based on the available data, we discovered evidence that suggests a relationship between MINOCA and APS patients. It is vital to raise awareness of this concern among the general public. Also required is the development and implementation of diagnostic and targeted treatment guidelines for patients with APS and MINOCA.

Intracardiac thrombus formation and thromboembolic events in children with cardiomyopathies: A single-center case series.

Intracardiac thrombosis and distant thromboembolic events are rare complications of patients diagnosed with any type of cardiomyopathies. The low prevalence of this entity makes it challenging and unfortunate for the patients and their families. This review aims to add to the current limited available data describing similar clinical entities.