High incidence of left ventricular thrombosis and systemic embolism in patients with left ventricular assist system]

The purpose of this study was to determine the incidence of left ventricular (LV) thrombosis and systemic embolism in 14 patients with LV assist systems. Echocardiography was used to detect LV wall motion abnormalities, intracavitary smoke-like echoes and thrombosis, and the effect of anticoagulant therapy was serially examined. During full assist of the circulation, the aortic valve did not open in any patient. Smoke-like echoes were observed in 9 patients (64%) and thrombi in 8 (57%). The thrombus developed within the first 3 assist days. Systemic anticoagulant therapy decreased the thrombus size in only 3 patients, but there was a possibility of intracranial or mediastinal bleeding in other 3 patients. Systemic embolism was noted in 7 of 11 autopsy patients (64%). The characteristic finding was that there were multiple embolized organs, such as the brain, kidneys, spleen and liver, in all patients. Development of a thrombus is a serious complication in all patients with LV assist systems. However, the problem does not lie in the assist system but in the left ventricle of the patient's own heart. It is also noteworthy that systemic anticoagulation is not effective for an LV thrombus. A new method of assisting the failing heart, or a new anticoagulant delivery technique for the LV cavity to prevent LV thrombus development is needed.     

Ischémie aiguë de membre inférieur,révélant un thrombus aortique flottant paranéoplasique

The floating mural thrombus of abdominal aorta is a rare and serious pathology detected as cause of peripheral and visceral embolism. Isolated aortic mural thrombosis is an unusual pathology occurring in an apparently normal aorta. A thorough search of embolic source must be initiated. Therapeutic management is based on systemic anticoagulation with the use of surgical approach in some cases.     

Pulmonary embolism and deep vein thrombosis complicating acute aortic dissection during medical treatment

Acute aortic dissection of Stanford type A with intramural hematoma was diagnosed based on computed tomography (CT) findings in a 60-year-old man. During medical treatment, pulmonary embolism and deep vein thrombosis developed. CT revealed thrombosis in the right pulmonary artery, and 99mTc pulmonary perfusion scintigraphy showed defects in the right lung field. CT showed thrombus in the common iliac vein. An inferior vena caval filter was placed because anticoagulation therapy was contraindicated. A CT scan before discharge showed no thrombus in the pulmonary artery or common iliac vein, but a newly captured thrombus was found inside the filter.     

Splanchnic vein thrombosis in severe acute pancreatitis: a 2-year, single-institution experience

ObjectivesThis study aimed to determine current practice in the management and outcome of splanchnic vein thrombosis complicating acute pancreatitis (AP).MethodsAn audit of prospectively collected data for all patients presenting with AP was conducted. Patients with splanchnic vein thrombosis were grouped according to vessel involvement and whether or not systemic anticoagulation was administered.ResultsOf 127 consecutive patients admitted with AP, 20 had splanchnic venous thrombosis; in all cases the thrombosis was associated with a severe attack of AP. Involvement of the splenic vein (SV), portal vein (PV) and superior mesenteric vein (SMV) was observed in 14, 10 and three patients, respectively. Involvement of more than one vessel was observed in six patients (SV and PV in four patients; SMV and SV in one patient; all three veins in one patient). Thromboses were colocalized with collections in 19 patients. Only four patients received systemic anticoagulation. Resolution of thrombosis was observed in six patients over a median of 77 days. No significant differences were observed in recanalization rates following anticoagulation (P= 0.076). No complications associated with systemic anticoagulation occurred. One patient developed liver failure associated with progressive PV thrombosis and one patient died.ConclusionsSplanchnic vein thrombosis is a relatively common observation in severe AP and is associated with pancreatic necrosis and peripancreatic collections. Recanalization is observed in almost a third of patients, irrespective of whether or not they receive systemic anticoagulation.     

The role of anticoagulation in acute myocardial infarction

The rule of anticoagulation therapy in the setting of an acute myocardial infarction has been debated for decades. The role of such therapy in reducing mortality, preventing deep venous thrombosis and pulmonary emboli, and in reducing the frequency of left ventricular thrombus formation and subsequent systemic embolization is discussed.     

Portal and superior mesenteric venous thrombosis treated with urokinase infusion via superior mesenteric artery]

Portal and mesenteric venous thrombosis is an uncommon disease, but clinically important, because it accounts for 5% to 15% of acute mesenteric ischemia. The diagnosis is often delayed because the conditions are nonspecific abdominal symptoms. In addition, when this occurs in young individual without any known predisposing factor, the diagnosis may become even more difficult. The treatment of mesenteric venous thrombosis involves anticoagulation therapy alone or in combination with surgery. The addition of thrombolytic therapy to the treatment of portal and mesenteric venous thrombosis may enhance the clearance of thrombus and hasten the clinical improvements. We present a case of mesenteric venous thrombosis treated with catheter-directed infusion of urokinase via the superior mesenteric artery and systemic anticoagulation.     

Very Late Stent Thrombosis after Discontinuation of Antiplatelet Agents during Anticoagulation Therapy in a Patient with Peri-stent Contrast Staining after Implantation of a Second-generation Drug-eluting Stent

A 54-year-old man was admitted to our hospital due to intermittent chest pain. He had a history of acute myocardial infarction, and peri-stent contrast staining had been observed at the stent implantation site. The patient previously underwent anticoagulation therapy for left ventricular thrombus and antiplatelet therapy to prevent stent thrombosis. More than one year after implantation of a drug-eluting stent, antiplatelet drugs were discontinued, and anticoagulant alone was prescribed according to the guidelines, which resulted in very late stent thrombosis. The risks of both bleeding and thrombosis must be fully considered when deciding whether or not to discontinue antiplatelet therapy during anticoagulation therapy.     

Thrombus Formation Following Transcatheter Aortic Valve Replacement

ObjectivesThis paper reviews the published data and reports 3 cases of thrombosis involving CoreValve (Medtronic, Minneapolis, Minnesota) and 1 involving Edward Sapien (Edwards Lifesciences, Irvine, California) devices. Three of these cases had pathological findings at autopsy.BackgroundOnly a limited number of cases of valve dysfunction with rapid increase of transvalvular aortic gradients or aortic insufficiency post-transcatheter aortic valve replacement (TAVR) have been described. This nonstructural valvular dysfunction has been presumed to be because of early pannus formation or thrombosis.MethodsThrough reviews of the published reports and 4 clinical cases, pathological and clinical findings of early valve thrombosis are examined to elucidate methods for recognition and identifying potential causes and treatments.ResultsThis paper presents 4 cases, 2 of which had increasing gradients post-TAVR. All 3 pathology cases showed presence of a valve thrombosis in at least 2 TAV leaflets on autopsy, but were not visualized by transthoracic echocardiogram or transesophageal echocardiogram. One case was medically treated with oral anti coagulation with normalization of gradients. The consequence of valve thrombosis in all 3 pathology patients either directly or indirectly played a role in their early demise. At least 18 case reports of early valve thrombosis have been published. In 12 of these cases, the early treatment with anticoagulation therapy resolved the thrombus formation and normalized aortic pressures gradients successfully.ConclusionsThese 4 cases elucidate the occurrence of valve thrombosis post-TAVR. Consideration should be given to treatment with dual antiplatelet therapy and oral anticoagulation in patients post-TAVR with increasing mean pressure gradients and maximum aortic valve velocity. Further research should be conducted to create guidelines for antithrombotic therapy following TAVR procedure.     

Mural Thrombus in the Normal-Appearing Descending Thoracic Aorta of a Chronic Smoker

Thrombus formation in an atherosclerotic or aneurysmal descending thoracic aorta is a well-described, frequently encountered vascular condition. In comparison, thrombus formation in a normal-appearing descending thoracic aorta is reported far less often.We describe the case of a 46-year-old woman who had splenic and renal infarctions secondary to embolic showers from a large, mobile thrombus in a morphologically normal proximal descending thoracic aorta. After the patient underwent anticoagulation, stent-grafting, and surgical bypass to correct an arterial blockage caused by the stent-graft, she resumed a relatively normal life. In contrast with other cases of a thrombotic but normal-appearing descending thoracic aorta, this patient had no known malignancy or systemic coagulative disorders; her sole risk factor was chronic smoking. We discuss our patient''s case and review the relevant medical literature, focusing on the effect of smoking on coagulation physiology.Key words: Anticoagulants/therapeutic use, aorta, thoracic/pathology/radiography/surgery, aortic diseases/diagnosis/etiology/therapy, diagnostic imaging, embolism/diagnosis/etiology, endothelium, vascular/physiology, risk factors, smoking/physiopathology, thrombosis/diagnosis/etiology/surgery/therapyWe report the case of a woman who had mural thrombus in a normal-appearing descending thoracic aorta (NADTA). Her only risk factor was chronic smoking. Smoking can cause immediate microscopic changes in the vascular endothelium that can be as prothrombotic as an aneurysm or atherosclerotic plaque. We discuss our patient''s case and review the relevant medical literature.     

Should anticoagulants be administered for portal vein thrombosis associated with acute pancreatitis?

Venous complications in patients with acute pancreatitis typically occur as a form of splenic, portal, or superior mesenteric vein thrombosis and have been detected more frequently in recent reports. Although a well-organized protocol for the treatment of venous thrombosis has not been established, anticoagulation therapy is commonly recommended. A 73-year-old man was diagnosed with acute progressive portal vein thrombosis associated with acute pancreatitis. After one month of anticoagulation therapy, the patient developed severe hematemesis. With endoscopy and an abdominal computed tomography scan, hemorrhages in the pancreatic pseudocyst, which was ruptured into the duodenal bulb, were confirmed. After conservative treatment, the patient was stabilized. While the rupture of a pseudocyst into the surrounding viscera is a well-known phenomenon, spontaneous rupture into the duodenum is rare. Moreover, no reports of upper gastrointestinal bleeding caused by pseudocyst rupture in patients under anticoagulation therapy for venous thrombosis associated with acute pancreatitis have been published. Herein, we report a unique case of massive upper gastrointestinal bleeding due to pancreatic pseudocyst rupture into the duodenum, which developed during anticoagulation therapy for portal vein thrombosis associated with acute pancreatitis.     

Immediate anticoagulation for intracardiac thrombus in acute cardioembolic stroke.

To assess the efficacy of immediate anticoagulation therapy on intracardiac thrombus formation in acute cardioembolic stroke, serial two-dimensional echocardiographic examinations were performed in 25 patients with acute cardioembolic stroke. Anticoagulation therapy was commenced within two days of onset in 7 patients (group A) but not in 18 patients (group B). Appearance or enlargement of intracardiac thrombi were not detected in group A but were noted in 7 patients (39%) of group B. Recurrence of systemic embolism was demonstrated in 3 patients (17%) of group B. There were no serious hemorrhagic complications in either group. Immediate anticoagulation could, therefore, be effective in preventing intracardiac thrombus formation and the consequent recurrence of systemic embolization in acute cardioembolic stroke. Because the study was preliminary and not randomized, further randomized study is desirable to establish the efficacy of immediate anticoagulation therapy.     

Thrombotic risk in patients with aortic bioprostheses

Thrombosis of Mosaic aortic valve bioprostheses occurring at more than one month after surgery occurs in 0.8% (95% CI 0.33-1.67%) of patients. In the two cases reported here, each patient had risk factors for thrombus formation, namely severe left ventricular impairment in one patient, while the other patient was heterozygous for prothrombin variant G20210A. The cases were treated successfully, by thrombolytic therapy with streptokinase in the first case, and by repeat aortic valve replacement in the second case. Thrombosis of bioprosthetic valves in the aortic position is rare, and a period of anticoagulation postoperatively does not invariably protect against this serious complication. In conclusion, patients with risk factors for thrombus formation should be considered for long-term anticoagulation.     

Anticoagulation and delayed bowel resection in the management of mesenteric venous thrombosis

Acute mesenteric venous thrombosis is potentially lethal because it can result in mesenteric ischemia and,ultimately,bowel infarction requiring surgical intervention.Systemic anticoagulation for the prevention of thrombus propagation is a well-recognized treatment modality and the current mainstay therapy for patients with acute mesenteric venous thrombosis.However,the decision between prompt surgical exploration vs conservative treatment with anticoagulation is somewhat difficult in patients with suspected bowel ischemia.Here we describe a patient with acute mesenteric venous thrombosis who presented with bowel ischemia and was treated with anticoagulation and delayed short-segment bowel resection.     

Treatment of left atrial thrombosis by low-molecular-weight heparin. A preliminary study of 6 cases

Left atrial thrombosis is a serious complication of atrial fibrillation because of its embolic potential, especially for the cerebral circulation. These thrombi are usually treated by oral anticoagulation. The authors studied the efficacy and tolerance of a low molecular weight heparin. Enoxaparin, in the treatment of this condition. This was a prospective study carried out over a 1 year period. Patient recruitment came from the transoesophageal echocardiography laboratory: of 15 thrombi detected, 6 were treated by ambulatory Enoxaparin therapy. Five of the 6 patients had no signs of left atrial thrombosis after 3 weeks of Enoxaparin therapy. The left atrial thrombus of the 6th patient remained hyperechogenic and had decreased in length from 27 to 24 mm. No cases of bleeding, haematoma, embolism or thrombopenia were observed with this treatment. This preliminary study shows that low molecular weight heparin may be used as an alternative to classical oral anticoagulation for the treatment of left atrial thrombosis.     

Role of thrombolytic treatment in thrombosis of valvular prostheses. Apropos of 2 cases and review of the world literature

The authors report 2 cases of thrombolytic therapy by Urokinase at the dose of 4 500 U/kg/hour, for 24 hours, in patients with thrombosis of a Bjork aortic and Lillehei mitral valve prostheses, and assess the efficacy with a review of the world literature. The first case was a 65 year old woman who received a Bjork No 25 aortic valve prosthesis for aortic regurgitation. Two years later oral anti-vitamin K anticoagulants were replaced by an association of Aspirin-Persantine. She developed acute pulmonary oedema secondary to thrombosis of her valve during the fifth postoperative year. Treatment with Urokinase was successful (4 500 U/kg/hour for 24 hours). The second cases was a 33 year old woman who received a Lillehei No 27 mitral valve prosthesis for mitral regurgitation due to infective endocarditis. Six years later, during a period of apparently ineffective oral anticoagulation, she developed subacute pulmonary oedema due to thrombosis of her prosthesis. Urokinase therapy was successful after 4 hours, but the valve surface area on cardiac catheterisation was decreased and elective reoperation to change the prosthesis was decided upon. Prosthetic valve thrombosis is a serious complication with an operative mortality of 68.6% (35 deaths out of 51 reoperations in the worl literature) whilst the efficacy of thrombolytic therapy would appear to be about 80%. When thrombosis is progressive, the valve has to be changed surgically, but when it is secondary, thrombolytic therapy at least helps the patient survive the acute phase.     

Thrombosis of abdominal aorta in congenital afibrinogenemia: case report and review of literature

Thrombotic events in congenital hypo‐afibrinogenemia have been rarely reported, either in association or not with replacement therapy or thrombotic risk factors. We describe clinical findings and management of thrombosis of abdominal aorta with peripheral embolism in a patient with congenital afibrinogenemia. A review of arterial thrombosis in inherited hypo‐afibrinogenemia was also performed. The patient with a severe bleeding history requiring prophylaxis with fibrinogen concentrates (FC) was admitted for ischaemia of the 4th right toe. An angio‐CT of abdominal aorta showed a thrombosis from the origin of renal arteries to the carrefour with a distal floating part. No thrombotic risk factors were found; a previous traumatic lesion of aortic wall might have triggered the thrombus formation, whereas the role of FC prophylaxis remains uncertain. The patient was successfully treated with FC, enoxaparin followed by fondaparinux, and low‐dose aspirin without bleeding or thrombosis recurrence. After 2 years, aortic thrombus was almost completely recovered. Sixteen hypo/afibrinogenemia patients with arterial thrombosis were found in Literature, showing that thrombosis often occurs at a young age, involves large vessels, its recurrence is not unusual, and therapeutic strategy is not defined yet. Our therapeutic approach was effective and also safe, but further studies are needed to improve the knowledge of pathogenesis and the anti‐thrombotic management in this peculiar setting.     

Mechanical Prosthetic Valve Thrombosis: Case Report and Review of the Literature

Mechanical prosthetic valve thrombosis is a life-threatening complication necessitating immediate intervention. The presenting signs and symptoms of this illness are somewhat variable, but physical examination and transesophageal echocardiography enable rapid diagnosis. To avoid catastrophic complications, valve replacement or debridement, or thrombolysis in the correct setting, must be performed without delay. It is not entirely clear which therapy is superior. For any given patient, the risks of thrombolytic therapy, including bleeding, systemic embolism, and failure to restore valvular function, must be weighed against the risks of surgical intervention. Once the decision is made to operate, the choice of valve replacement versus debridement is one best made intraoperatively, upon visual inspection of the valve apparatus. Despite aggressive therapy, morbidity and mortality from prosthetic valve thrombosis and its treatment are not trivial. Fortunately, with current prosthetic devices and aggressive prophylactic anticoagulation, the incidence of prosthetic valve thrombosis remains low. Antiplatelet therapy may offer additional benefit to patients being prophylaxed with warfarin. This report details the case of a woman with aortic and mitral prosthetic valves who presented with heart failure and evidence of severe aortic prosthetic dysfunction after a period of suboptimal anticoagulation. She successfully underwent debridement of the mitral prosthesis and replacement of the aortic valve. The relevant literature is reviewed.     

Deep vein and intracardiac thrombosis during the post-partum period in Behçet’s disease

A 22-year-old woman presented on the 10th post-partum day with deep vein thrombosis involving the right ilio-femoral and popliteal veins. This thrombosis was refractory to conventional anticoagulation and subsequently over a period of 6 weeks progressed to involve inferior vena cava and right ventricle. A diagnosis of Behçet’s disease was made on the clinical grounds of fever, night sweats, and recurrent oral ulcers. In view of refractory thrombosis, anticoagulation with lepirudin was commenced followed by thrombolysis with streptokinase. After thrombolysis, anticoagulation was switched to fondaparinux. Intracardiac thrombus, oral ulcers, constitutional symptoms, and inflammatory indices resolved on 20 mg of oral prednisolone. This case highlights that management of thrombosis unresponsive to conventional anticoagulation requires careful consideration of the underlying conditions, the sites of thrombosis, as well as of the available treatment options. Intravenous lepirudin is a valuable therapeutic option when anticoagulation with warfarin or LMWH is not efficacious. Thrombolytic therapy may be used to treat intracardiac thrombi more rapidly, and possibly more efficiently, than surgery. The addition of corticosteroids or other immunosuppressive drugs is necessary in order to achieve a full resolution of thrombosis.     

Isolated splenic vein thrombosis secondary to splenic metastasis： A case report

INTRODUCTIONIsolated splenic vein thrombosis is a rare clinical syndrome that may lead to left-sided portal hypertension.Metastasis to the spleen from solid tumors is also considered rare.When identified it usually occurs in the setting of widely dissemin…     

Isolated splenic vein thrombosis secondary to splenic metastasis: A case report

A 49-year-old, previously healthy woman sought treatment for abdominal pain. Colonoscopy revealed ascending colon cancer. Computed tomography and angiography showed splenic metastasis and thrombosis extending from the splenic vein to the portal vein. She underwent right hemicolectomy, splenectomy, and distal pancreatomy. Histological findings showed no malignant cell in the splenic vein which was filled with organizing thrombus. We postulate the mechanism of splenic vein thrombosis in our case to be secondary to the extrinsic compression of the splenic vein by the splenic metastasis or by the inflammatory process produced by the splenic metastasis. In conclusion, we suggest that splenic metastasis should be added to the list of differential diagnosis which causes splenic vein thrombosis. In the absence of other sites of neoplastic disease, splenectomy seems to be the preferred therapy because it can be performed with low morbidity and harbors the potential for long-term survival.