ABSTRACT
Introduction: Clinically relevant pulmonary embolism (PE) related to pacemaker leads is reported in up to 3.5% of cases of implantations. We reported a particular case of acute massive PE in a patient bearer of a Cardiac Resynchronization Therapy-Defibrillator (CRT-D). Case presentation: A 49-year-old man presented to our ER reporting dyspnea and localized pain to the left hemithorax. Past medical history included HFrEF due to idiopathic dilated cardiomyopathy complicated by apical thrombosis, CRT-D, Charcot-Marie-Tooth syndrome, dyslipidemia, and a hepatic nodule undergoing diagnosis. Recently, he reported COVID-19 and successive pleuropneumonia requiring hospitalization. At home, he was taking Acenocoumarin, Sacubitril/Valsartan 97/103mg bid, Carvedilol 6.25mg bid, Digoxin 0.0625mg, and Canrenon 50mg with questionable adherence. On physical examination, he was pyretic, mildly hypotensive and hypoxemic. An ECG showed atrio-guided biventricular stimulation at 110 bpm. A transthoracic echocardiogram (TTE) revealed biventricular disfunction and dilation, mitral and tricuspid regurgitation, PAPs 60 mmHg, and a thrombotic formation in the left ventricle apex. Blood tests found elevated D-Dimer and infection markers, INR 1.1. A CTangiography confirmed a bilateral acute massive PE associated with lung consolidations and left pleural effusion. We excluded deep vein thrombosis in the lower limbs. Patientwas admitted to CCU and treatedwith intravenous heparin, antibiotics, and support therapy. After one week, we performed a transesophageal echocardiogramthat confirmed the previous TTE except for a minor PAPs and unknown thrombotic formations on the atrial side of the tricuspid valve, adhering to CRT-D leads, pedunculated, highly mobile, the largest with an area of 1.9cm2. Cardiac surgery wasn't indicated;we excluded thrombophilia and thoracic cancer. Patient is still hospitalized, asymptomatic and with a precarious cardiovascular status. Discussion(s): The incidence of asymptomatic clot adhering to cardiac device's leads found by echocardiography is 1.4%, and thromboembolic complications are even rarer, especially after years from the implant. In our patient, the right atrium thrombosis is probably the cause of PE, and possible precipitating factors were pneumonia or unknown hepatic neoplasm. In the diagnostic workup, TTE probably wasn't sensitive enough to detect those thrombi. Conclusion(s): We presented a particular case of PE in a relatively young patient affected with HFrEF. Even if thrombosis related to pacemaker leads is rare, it should be considered as a possible cause of PE in a patient bearer of a cardiac stimulating device. (Figure Presented).
ABSTRACT
The recent CoViD-19 emergency, a dramatic issue for our health, and the vexata quaestio of the existing buildings recovery, especially of the neighborhood, are the ends of an Ariadne's thread that must help us find an exit from the two huge problems. These issues, coupled by the isolation constrain, can be converted in a great opportunity by using targeted choices, supported by sustainability criteria that are now unavoidable. In the present paper, a specific suburban area- former Fondo Basile by architect Filippo Rovigo, on the northern edge of Messina was selected. For this area - following the original indications formulated by the emerging "neorealist" culture for garden cities - we intend: To redefine barrier-free paths;to add green and blue infrastructures;to evaluate incidences on energy performance;to redesign interior spaces to accept the need for sterilization and “flexible” furnishings;to experiment with functionalized surfaces (self-cleaning, antibacterial, heat-insulating);to introduce ad hoc home automation. Therefore, it is necessary to start from a very serious accident on which we stumbled exploiting this experience in order to look at the virus as an opportunity for a general rebirth of the neighbourhood. This latter can be based on new or experimental concepts in order to allow a sustainable restoration of the Modern Architecture, addressed to the second post-war period heritage, not guaranteed by the constrained regime provided for by the Cultural Heritage Code. This possibility is back in the fore thanks to a more recent strategic direction for the protection of "new landscapes" promoted by the Regional Department for Sicilian culture and identity. © 2020, Universidad Politecnica de Valencia. All rights reserved.