Two cases of complications of the thrombolysis of right heart free-floating thrombi with pulmonary embolism: important role of echocardiographically based management

We present two cases where successful thrombolysis of right heart thrombi and pulmonary embolism was accompanied by serious adverse events. In patient 1 with massive pulmonary thromboembolism, transesophageal ultrasound revealed large right atrial thrombus entrapped in a patent foramen ovale. Initial treatment with heparin was substituted with thrombolysis, which resulted in clinical improvement and dissolution of right heart thrombus but was followed by fatal intracerebral haemorrhage. In patient 2, thrombolysis caused mobilisation of thrombotic mass as evidenced by disappearance of thrombus on ultrasound. Massive pulmonary thromboembolism resulted in circulatory collapse. Short cardiopulmonary resuscitation restored spontaneous circulation and the patient recovered completely.     

二尖瓣球囊成形术在二尖瓣狭窄合并左房血栓形成中的应用

目的:评价经皮二尖瓣球囊成形术治疗二尖瓣狭窄伴左房血栓形成的疗效、安全性。方法:56例伴有左房血栓形成患者术前经正规华法林抗凝治疗后,采用改良的房间隔定位法即井字定位法及运用跨二尖瓣技巧对二尖瓣狭窄伴左房血栓形成患者行逐步球囊扩张,以血流动力学评估手术前后即刻左房压、二尖瓣跨瓣压差及二尖瓣口面积,并进行手术后随访,观察有无体循环血栓栓塞等并发症。结果:与术前相比较,术后左心房平均压下降[(21.6±3.7)mmHg(1mmHg=0.133kPa)∶(35.1±4.2)mmHg]、二尖瓣跨瓣压差显著下降[(7.1±3.1)mmHg∶(16.8±4.5)mmHg)],二尖瓣口面积增大[(1.65±0.28)cm2∶(0.71±0.14)cm2],差异极有统计学意义(均P<0.01),心功能明显改善。超声心动图随访结果表明,经皮二尖瓣球囊成形术疗效稳定,无血栓栓塞并发症发生。结论:左房血栓形成仅为经皮二尖瓣球囊成形术的相对禁忌证,对于经充分华法林抗凝治疗的患者而言,经皮二尖瓣球囊成形术操作技术的改进能明显改善其症状,是安全有效的。     

Giant pedunculated thrombus with normal left ventricular systolic function mimicking myxoma

A 74-year-old woman with a history of essential thrombocythemia was admitted to the Coronary Care Unit because of atypical chest pain. The transthoracic echocardiogram showed normal left ventricular (LV) diameter and preserved regional and global systolic function. A pedunculated mobile mass measuring 25 mm × 14 mm was visualized in the LV cavity, attached to the midanterior wall. Because of the typical echocardiographic appearance, a myxoma was suspected. The patient evolved with left hemiparesis and negative T-waves in the electrocardiogram. Left ventriculotomy with excision of the ventricular mass was performed. Histopathological examination revealed an organized thrombus.     

Atrial reconstruction,distal gastrectomy with Ante-situm liver resection and autotransplantation for hepatocellular carcinoma with atrial tumor thrombus: A case report

Rationale:Hepatocellular with tumor thrombi extending into 3 hepatic veins (HVs) and right atrium presents as a real clinical challenge. We report the first documented case of surgical resection of an advanced hepatocellular carcinoma (HCC) with extensive invasion to distal stomach, atrium and hepatic vasculatures.Patient concerns:We present a case of 48-years old man with abdominal mass accompanying shortness of breath after activities.Diagnoses:Preoperative examination revealed giant HCC with tumor thrombi extending into portal vein, HVs, inferior vena cava, and atrium.Interventions:Distal stomach involvement was confirmed at surgery and, distal gastrectomy, atrial reconstruction and ante-situm liver resection and autotransplantation under cardio-pulmonary bypass were performed.Outcomes:The operation time was 490 minutes, extracorporeal circulation time 124 minutes, and anhepatic time 40 minutes. Postoperative follow-up revealed normal hepatic and cardiac function with no sign of recurrence.Lessons:This case illustrates that the extensive invasion of HCC to major vasculature and adjacent organs may not necessarily preclude the liver autotransplantation with multi-visceral resection as the treatment option of extremely advanced HCC patients.     

TAFIa, PAI-1 and α2-antiplasmin: complementary roles in regulating lysis of thrombi and plasma clots

PAI-1 and alpha(2)-antiplasmin (alpha(2)AP) are the principal direct inhibitors of fibrinolytic proteases. Thrombin activatable fibrinolysis inhibitor (TAFI), a plasma procarboxypeptidase activated by thrombin-thrombomodulin to form TAFIa, also regulates fibrinolysis by modulating fibrin. In this study, the relative contributions of PAI-1, alpha(2)AP and TAFIa to inhibition of lysis were assessed. In platelet-poor plasma clots, alpha(2)AP, TAFIa and PAI-1 all inhibited lysis, as shown by the addition of neutralizing antibodies to alpha(2)AP and PAI-1 +/- CPI, a potato carboxypeptidase inhibitor. alpha(2)AP played the largest role in regulating plasma clot lysis, but neutralization of inhibitors in combinations was more effective in shortening lysis times, with a maximal effect when all three inhibitors were neutralized. In platelet-rich clots, a larger contribution of PAI-1 was evident. Tissue plasminogen activator induced lysis of model thrombi, made from whole blood, was approximately doubled on incorporation of CPI, illustrating a substantial contribution of TAFIa to inhibition of thrombus lysis. Similar increases in thrombus lysis were observed on inclusion of neutralizing antibodies to PAI-1 and alpha(2)AP, with alpha(2)AP playing the dominant role. Maximal thrombus lysis occurred upon neutralization of all three inhibitors. These observations suggest that, despite the differences in concentrations and activities of inhibitors, and the different modes of action, the roles of the three are complementary in both plasma clot lysis and thrombus lysis.     

直肠家族性腺瘤性息肉与癌组织中COX-2蛋白表达及意义

经病理证实合并门脉癌栓的肝癌患者50例。其中28例行肝癌切除，术中门脉取栓及肝切除无水酒精注射，术后肝动脉灌注栓塞化化主门脉化疗；另22例行肝癌切除，门脉取栓，术中未用无水酒精，术后无化疗，结果示观察组与对照组相比，术后并发症分别为7.1%和9.0%，术后0.5,1,3年生存分别为80.8%,73.1%,26.9%和71.4%,33.3%,0%。肝切除联合导管栓塞化疗及无水酒精注射是提高合并门脉癌栓的肝癌远期疗效的有效措施。     

Left ventricular thrombi after short-term high-dose anticoagulants in acute myocardial infarction

To examine the effect of short-term, high-dose anticoagulationon the subsequent occurrence of left ventricular (LV) thrombiafter a first anterior wall acute myocardial infarction (AMI),21 patients received placebo and 21 high-dose anticoagulantsduring the first 10 days of the acute infarction. They werestudied with cross-sectional echocardiography 10 days and 1-3and 6 months post infarction. At 1 month, 6 of 7 thrombi presentin the placebo group at 10 days were still visible. No thrombiwere detected at 10 days in the anticoagulation group, but 6patients had developed a LV thrombus at 1 month. These 12 patientswith LV thrombi were subsequently treated with oral warfarinfor 2 months, after which all thrombi had disappeared. Warfarinwas then discontinued, and a thrombus had recurred in 5 patientsafter 6 months. Apical akinesis at 10 days a predictor for thrombuswith a sensitivity and specificity of 100% and 72.2% respectively. Three of the 13 patients with LV thrombi suffered stroke incontrast to none without thrombi (P=0.025). We conclude that after discontinuation of short-term high-doseanticoagulation therapy in anterior AMI, LV thrombi may developrapidly and lead to embolic complications, particularly in patientswith persisting apical akinesis.     

Lead Thrombi Associated with Externalized Cables on Riata ICD Leads: A Case Series

St. Jude Riata family ICD leads are subject to an FDA class I recall due to insulation failure, cable extrusions, and a high rate of electrical failures. We present multiple cases of large intravascular thrombus formation adherent to externalized conductor cables on Riata leads. Our observations highlight a previously unknown risk of large or calcified thrombus formation involving externalized conductors. We suggest that these leads should be screened for thrombi prior to potential lead extraction to determine the safest approach. Serial echocardiography may help detect progressive thrombus formation. The role of systemic anticoagulation for prevention or treatment of these thrombi remains unclear.