scholarly journals Right Heart Thrombus and Pulmonary Embolism in Patients with Life-Threatening Bleeding: Management of a Complex Condition

2021 ◽  
Author(s):  
Enrico Bentivegna ◽  
Michelangelo Luciani ◽  
Valerio Spuntarelli ◽  
Giorgio Sesti ◽  
Flavia Del Porto ◽  
...  
Keyword(s):  
Therapeutic Strategy ◽  
Bleeding Risk ◽  
Right Heart ◽  
Bleeding Management ◽  
Critical Situation ◽  
Haemodynamic Parameters ◽  
Complex Patients ◽  
Life Threatening ◽  
Uncommon Condition ◽  
In Transit

AbstractRight heart thrombus (RHT) in transit is an uncommon condition associated with high mortality. Increased use of echocardiography has allowed an easier detection of RHT; however, there is no consensus about the most appropriate management of this critical situation. Therapeutic strategy should be decided according to patient’s haemodynamic parameters, clinical data, and bleeding risk. This paper, referring to the most current evidences, underlines the difficulty to establish the best therapeutic strategies in RHT among complex patients as there are no relevant guidelines. In some conditions, multidisciplinary management is the best way to find the most correct therapy despite the bad prognosis.

scholarly journals Acute pulmonary embolism in COVID-19 patient: a case report of free-floating right heart thrombus successfully treated with fibrinolysis

2020 ◽  
Author(s):  
Fernando Scudiero ◽  
Antonino Pitì ◽  
Roberto Keim ◽  
Guido Parodi
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Retrospective Studies ◽  
Right Heart ◽  
Clinical Issue ◽  
Systemic Thrombolysis ◽  
Case Summary ◽  
High Prevalence ◽  
Life Threatening ◽  
Complex Scenario

Abstract Background Despite the fast-growing understanding of the coronavirus disease 2019 (COVID-19), patient management remains largely empirical or based on retrospective studies. In this complex scenario, an important clinical issue appears to be represented by the high prevalence of thromboembolic events, but the data regarding high-risk pulmonary embolism (PE) is still not available. Case summary A patient with COVID-19 developed sudden shortness of breath and hypoxia. Early echocardiographic diagnosis of high-risk PE related to right heart thrombus was performed. Systemic thrombolysis was administered with excellent clinical and haemodynamic response. Discussion Pulmonary thromboembolism is a common occurrence in severe COVID-19 infection. In our experience, systemic thrombolysis proved to be effective and for this reason may be considered for life-threatening PE in COVID-19 patients.

scholarly journals A Giant Right Heart Thrombus-in-Transit: The Challenge of Anticoagulation in Factor V Leiden Thrombophilia

2018 ◽  
Vol 2018 ◽  
pp. 1-4
Author(s):  
Andrew Chu ◽  
Thu Thu Aung ◽  
Minni Shreya Arumugam ◽  
Mauricio Danckers ◽  
Mohi Mitiek ◽  
...  
Keyword(s):  
Oral Anticoagulants ◽  
Single Point ◽  
Factor V Leiden ◽  
Single Point Mutation ◽  
Homozygous Mutation ◽  
Factor V ◽  
Right Heart ◽  
Blood Clots ◽  
History Of ◽  
In Transit

Factor V Leiden (FVL) is an autosomal dominant condition resulting in thrombophilia. Factor V normally acts as a cofactor for prothrombinase, helping cleave prothrombin to thrombin. A single point mutation in it disrupts factor V, making it unreceptive to protein C and increasing the risk of thrombosis. FVL mutation associated with right heart thrombus is a rare entity. Right heart thrombus or right heart thrombus-in-transit is associated with high mortality. We present a 51-year-old male with a past medical history of FVL homozygous mutation and recurrent blood clots, who has failed multiple different oral anticoagulants. He presented to the hospital with symptoms of shortness of breath and subsequently found to have a giant right heart thrombus. He was treated with surgical embolectomy. This case underscores the challenges faced by patients with FVL and recurrent blood clots.

Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

2018 ◽  
Vol 52 (3) ◽  
pp. 195-201 ◽  
Author(s):  
Prasoon P. Mohan ◽  
John J. Manov ◽  
Francisco Contreras ◽  
Michael E. Langston ◽  
Mehul H. Doshi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Bleeding Risk ◽  
Right Heart ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Ultrasound Assisted ◽  
Vascular Obstruction ◽  
The Right ◽  
Pulmonary Vascular Obstruction

Purpose: Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution. Methods: The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. Results: Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT. Conclusion: Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

Adverse reactions to medication

2019 ◽  
pp. 103-114
Author(s):  
Tomasz Bajorek ◽  
Jonathan Hafferty
Keyword(s):  
Adverse Effect ◽  
Adverse Effects ◽  
Adverse Reactions ◽  
Bleeding Risk ◽  
Inpatient Setting ◽  
Extrapyramidal Side Effects ◽  
Inpatient Psychiatry ◽  
Drug Induced ◽  
Threatening Condition ◽  
Life Threatening

Adverse reactions to medication represent a major issue in inpatient psychiatry. This chapter systematically explores the most relevant, concerning, and problematic adverse effects routinely encountered in an inpatient setting. It describes the typical presentation, pathophysiology, incidence, and practical management of these problems. Extrapyramidal side effects including acute dystonia, drug-induced parkinsonism, akathisia, and tardive dyskinesia are considered before the chapter explores the rare but potentially life-threatening condition of neuroleptic malignant syndrome. Other adverse effects common to antipsychotics that are described include hyperprolactinaemia and psychotropic-induced arrhythmias including QTc prolongation. Sexual dysfunction is an under-recognized and undertreated adverse effect common to several classes of psychotropic medication and is also considered. Focusing on antidepressants, the chapter reviews the frequently encountered issue of hyponatraemia as well as serotonin syndrome and selective serotonin reuptake inhibitor-induced bleeding risk. Finally, the chapter addresses perinatal considerations for psychotropic drugs.

Palliation of head and neck cancer

2019 ◽  
pp. 433-460
Keyword(s):  
Head And Neck Cancer ◽  
Head And Neck ◽  
Neck Cancer ◽  
Severe Pain ◽  
Symptom Control ◽  
Bleeding Management ◽  
Complex Anatomy ◽  
Life Threatening ◽  
Difficult Area

As a consequence of its location, head and neck cancer can affect breathing, speech, swallowing, and most of the special senses, and can impact massively on quality of life and body image. The head has a particularly complex anatomy in a very restricted space, and tumours have the potential to cause very complex and severe pain, often with a major neuropathic element. Disease in the mouth can lead to fistulae and aspiration pneumonia. Some tumours carry a risk of life-threatening bleeding. Management of all of these and other features of advanced head and neck cancer require skill and knowledge. Head and neck cancer, perhaps more than any other cancer, involves the total person, and requires a multidisciplinary response. This chapter summarizes the clinically important aspects of the main pathologies, and discusses a practical approach to symptom control of this difficult area.

scholarly journals Ureteral iliac artery fistula in idiopathic retroperitoneal fibrosis: A case report

2020 ◽  
Vol 92 (2) ◽  
Author(s):  
Eugenio Di Grazia ◽  
Tiziana La Malfa ◽  
Gherardo Gasso
Keyword(s):  
Iliac Artery ◽  
Retroperitoneal Fibrosis ◽  
Common Iliac Artery ◽  
Unknown Etiology ◽  
Gross Hematuria ◽  
Idiopathic Retroperitoneal Fibrosis ◽  
First Case ◽  
Life Threatening ◽  
Uncommon Condition ◽  
The Right

Ureter-arterial fistula (UAF) is an uncommon condition. The presentation is usually a life-threatening intermittent massive gross hematuria and the diagnosis is still a challenge for urologist. Idiopathic Retroperitoneal fibrosis (IRF) is a condition of unknown etiology characterized by a highly fibrotic retroperitoneal mass that frequently causes ureteral obstruction. To our knowledge we report the first case describing the UAF in a patient suffering from IRF. We hypothesize that inflammation and fibrosis resulted in fixation of the ureter to the adjacent artery causing a fistulous path. UAF was managed by deploying a 10 x 59 mm endo-graft at the intersection of common iliac artery bifurcation with the right ureter. Post treatment course was uneventful.

scholarly journals Combining antiplatelet and anticoagulant therapy in cardiovascular disease

Hematology ◽  
2020 ◽  
Vol 2020 (1) ◽  
pp. 642-648
Author(s):  
Geoffrey D. Barnes
Keyword(s):  
Randomized Clinical Trials ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Thrombotic Event ◽  
Bleeding Risk ◽  
Antithrombotic Agents ◽  
Thrombotic Risk ◽  
Coronary Syndrome ◽  
Combined Use ◽  
Life Threatening

Abstract Up to 10% of the >3 million Americans with atrial fibrillation will experience an acute coronary syndrome or undergo percutaneous coronary intervention. Therefore, concurrent indications for multiple antithrombotic agents is a common clinical scenario. Although each helps reduce thrombotic risk, their combined use significantly increases the risk of major bleeding events, which can be life threatening. In the past 5 years, a number of randomized clinical trials have explored different combinations of anticoagulation plus antiplatelet agents aimed at minimizing bleeding risk while preserving low thrombotic event rates. In general, shorter courses with fewer antithrombotic agents have been found to be effective, particularly when direct oral anticoagulants are combined with clopidogrel. Combined use of very low-dose rivaroxaban plus aspirin has also demonstrated benefit in atherosclerotic diseases, including coronary and peripheral artery disease. Use of proton pump inhibitor therapy while patients are taking multiple antithrombotic agents has the potential to further reduce upper gastrointestinal bleeding risk in select populations. Applying this evidence to patients with multiple thrombotic conditions will help to avoid costly and life-threatening adverse medication events.

scholarly journals P689 Surgical treatment of a right heart thrombus-in-transit with massive bilateral pulmonary embolism

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
C M Angelescu ◽  
I Hantulie ◽  
Z Galajda ◽  
I Mocanu ◽  
A T Paduraru ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Right Atrium ◽  
Intracardiac Thrombus ◽  
Severe Pulmonary Hypertension ◽  
Right Heart ◽  
Right Pulmonary Artery ◽  
The Right ◽  
In Transit ◽  
Right Heart Dysfunction

Abstract Introduction Right heart thrombi are rare, found in up to 20% of pulmonary emboli (PE), and associated with significantly increased mortality(1). A thrombus entrapped in a PFO is a rare form of right heart thromboembolism. Clinical Case A 73-year-old male patient who had dyspnea for 10 days, was transferred to our hospital for the surgical treatment of a cardiac tumor. We performed TTE which revealed a free floating, huge mass( measuring more than 8 cm long) in the right atrium, that protruded in the right ventricle, with high risk of embolization. Another smaller mass, attached to the interatrial septum. Severe right ventricular dysfunction and severe pulmonary hypertension were present. Contrast-enhanced computer tomography was performed, which revealed severe bilateral pulmonary artery emboli with complete occlusion of right pulmonary artery branch. Clinical and paraclinical data strongly suggested that the huge cardiac mass was a thrombus that originated from the lower extremity veins. TEE showed that the thrombus was entrapped through the PFO, with a smaller part in the left atrium and the biggest portion in the right atrium. The patient underwent an emergent on-pump surgical cardiac and right pulmonary artery embolectomy. The right atrium was opened and a huge intracardiac thrombus with a lengh of 14 cm extending from the coronary sinus, to PFO in the left atrium and also in the right ventricle was removed. The right branch of the pulmonary artery was opened and a large volume of clot- 9 cm long- was removed. The patient was removed from cardio-pulmonary by-pass (CPB) on high doses of norepinephrine and dobutamine and necessitated initiation of venous-arterial ECMO to support the severe right heart dysfunction. He was extubated after 10 days, with little improvement in the clinical status. Transthoracic echocardiography showed smaller right heart cavities), normal left ventricular function, but persistent severe RV dysfunction and severe pulmonary hypertension. In the thirteenth postoperative day, he installed cardio-respiratory arrest and he died. Discussion In this report we describe a case of a patient with a huge intracardiac thrombus, entrapped through a PFO, associated with massive pulmonary embolism, with late presentation in our hospital and severe refractory right heart dysfunction. He underwent successful embolectomy, which is a unique procedure in the treatment of an acute pulmonary embolism and entrapped thrombus in a PFO. Conclusion The treatment of choice for emboli-in-transit is controversial. In a recent review, surgical thromboembolectomy showed a trend toward improved survival and significantly reduced systemic emboli compared to anticoagulation. Thrombolysis in these patients may cause fragmentation of thrombus and systemic embolization, resulting in increased mortality. Management decisions should be made with multidisciplinary coordination and consideration of complicating factors such as PFO. Abstract P689 Figure. Extensive biatrial thrombus

Midgut volvulus secondary to congenital malrotation in pregnancy

2020 ◽  
Vol 13 (5) ◽  
pp. e234664 ◽  
Author(s):  
Eelyn Chong ◽  
David S Liu ◽  
Vishnupriya Rajagopal ◽  
Neil Strugnell
Keyword(s):  
Perinatal Outcomes ◽  
First Trimester ◽  
Small Bowel Resection ◽  
Emergency Laparotomy ◽  
Midgut Volvulus ◽  
Threatening Condition ◽  
Life Threatening ◽  
Uncommon Condition ◽  
Adverse Perinatal Outcomes ◽  
In Pregnancy

Midgut volvulus complicating congenital malrotation is a rare but life-threatening condition that can occur in pregnancy. We present a case of intestinal infarction resulting from midgut volvulus in a healthy 32-week pregnant woman who underwent emergency laparotomy and small bowel resection in the setting of fetal death in utero. This case highlights several challenging issues in diagnosing and managing this uncommon condition which leads to increased adverse perinatal outcomes. Prompt investigation and definitive surgical treatment are required when pregnant women present with bilious vomiting and new-onset abdominal or back pain especially beyond the first trimester.

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