Influence of LVAD Cannula Outflow Graft Flow Rate and Location on Fluid-Particle Interactions and Thrombi Distribution: A Primary Numerical Study.

A left ventricular assist device (LVAD) supports hemodynamics in heart failure patients. To deepen the understanding of hemodynamic changes and the movement of thrombi in the aorta, we examined three distinct LVAD blood flow rates across two implantation sites using the theory of computational fluid dynamics. Our findings revealed the complex dynamics of blood flow during cardiac systole under various scenarios. We also analyzed thrombi residence time and flow probabilities into aortic branches. Simulation results indicate that thrombi distribution in the aorta is significantly influenced by the location of the LVAD outflow graft and the flow rate. When the LVAD outflow graft is implanted into the ascending aorta, higher flow rates may reduce the risk of cerebral thrombosis. However, lower flow rates may reduce the risk of cerebral thrombosis while it is implanted into the descending aorta. The study may offer valuable insights into the LVAD implantation about the risk of cerebrovascular embolism.

Giant Left Ventricular Thrombus Rapidly Developing in an Extremely Short Period of Time in a Patient With Severe Systolic Dysfunction.

Although left ventricular thrombi (LVTs) are closely related to the prognosis of patients with systolic dysfunction, anticoagulation therapy is not recommended for the primary prevention of LVTs in patients with sinus rhythm heart failure. We report a case of a patient with systolic dysfunction who developed a giant LVT in an extremely short period of time (one month) after an infection. The LVT led to acute limb ischemia, gangrene, and death. Additionally, we incidentally detected pulmonary thrombosis in this patient.

Dynamic Perviousness: A Novel Imaging Marker for Predicting Mechanical Thrombectomy Outcomes in Acute Ischemic Stroke.

BACKGROUND: The predictive value of thrombus standard perviousness (SP) in acute ischemic stroke (AIS) for the technical success rates of mechanical thrombectomy (MT) or functional outcomes is not yet conclusive. We investigated the relationship between dynamic perviousness (DP) and revascularization results using time-dependent enhancement curve types determined with computed tomography (CT). METHODS: A retrospective analysis of 137 AIS patients was performed. DP was calculated as the thrombus attenuation increase (TAI) using three time points and categorized into four groups: (1) no enhancement (CNE); (2) late enhancement (CLE); (3) early enhancement with washout (CW); (4) early enhancement without washout (CNW). Associations with the technical success rate and functional outcomes were assessed. RESULTS: Late enhancement (CLE) had approximately two times higher odds for successful MT as compared to clots with other enhancement dynamics. The odds ratios (logistic regression model with CNW as the reference) for the TICI III scores were 4.04 (p = 0.067), 1.82 (p = 0.3), and 1.69 (p = 0.4) for CLE, CW, and CNE, respectively. The NIHSS scores at discharge and mRS scores at three months showed regression coefficients (linear regression model with CNW as reference) of -3.05 (p = 0.10), -1.17 (p = 0.51), and -1.24 (p = 0.47); and -1.30 (p = 0.097), -0.85 (p = 0.25), and -0.15 (p = 0.83) for CLE, CW, and CNE, respectively. CONCLUSIONS: Thrombi with late enhancement patterns showed a higher revascularization rate and better outcomes as compared to clots with early uptake or no washout.

Right Lower Pulmonary Vein Thrombi and Right Upper Pulmonary Vein Thrombi Connected on the Anterior Wall of the Left Atrium.

The interaction between the right upper pulmonary vein (RUPV) and the right lower pulmonary vein (RLPV) is poorly understood. In this paper, using transesophageal echocardiography (TEE) and 80-slice multidetector computed tomography (80-MDCT), we report that the RUPV thrombi and the RLPV thrombi invade the left atrium (LA) and reach the anterior wall of the LA. To our knowledge, this is the first study to directly show the connection between the RUPV thrombi and the RLPV thrombi on the anterior wall of the LA using TEE and 80-MDCT.

Outcomes after radical nephrectomy with vena cava thrombectomy using multidisciplinary approach: A single center experience.

INTRODUCTION: To describe the perioperative outcomes in patients treated with radical nephrectomy with cava thrombectomy at all thrombi levels using a multidisciplinary approach, with or without extracorporeal circulation (ECC), and to identify factors associated with perioperative morbidity. METHODS: We retrospectively identified 42 patients who were diagnosed with renal cell carcinoma (RCC) and a vena cava thrombus and treated with radical nephrectomy and cava thrombectomy by a double surgical team at Lyon University Hospital from 2008 through 2021. The surgeons operated in the cardiothoracic operating theater to proceed with median sternotomy or ECC, if necessary. The primary endpoint of this study was perioperative morbidity and mortality assessed using the Clavien-Dindo scale. Complications were recorded until 90 days after surgery, and those classified as grade IIIa or higher were considered high-grade complications. RESULTS: Overall, 32 (76%) patients required ECC. No intraoperative mortality occurred; however, two patients (5%) died within 30 days. Complications occurred within 30 days in 30 patients (72%), with severe complications observed in 10 patients (24%). No further complications occurred between 30 and 90 days. Multivariate analysis revealed that age, thrombus level, ECC, American Society of Anesthesiologists physical status, symptoms, and metastasis at presentation were not significantly associated with high-grade complications (P>0.05). CONCLUSIONS: Multidisciplinary approach is essential and frequent use of ECC, when achieved by a trained team, may facilitate surgery, and is associated with low perioperative morbidity, especially for patients with high-level thrombi. LEVEL OF EVIDENCE: IV.

An Unusual Case of Cardiac Mass: A Multimodal Approach in Diagnosis and Treatment.

Diagnosing intracardiac masses poses a complex, multimodal challenge. We present the case of a 72-year-old woman with a history of rheumatic fever leading to mitral stenosis and a previous mitral valve commissurotomy who reported fatigue, weakness, and palpitations over the past three months. Echocardiography revealed a tumor (53 × 40 mm) in the enlarged left atrium, attached by a wide base to the left atrium wall, exhibiting variable densities. Computerized tomography identified a heterodense mass (53 × 46 × 37 mm) with similar attachments. Angiography showed two branches from the circumflex artery intricately associated with the mass. Despite unsuccessful embolization of the mass' blood supply, surgical intervention including mitral valve replacement, tricuspid valve annuloplasty, and tumor removal was pursued. Pathohistological analysis confirmed the mass as a thrombus. During the postoperative follow-up, the patient presented with no complaints. Follow-up echocardiography indicated the normal function of the mechanical mitral valve prosthesis and the absence of intracardiac masses. While it remains unknown whether this neovascularization is specific to patients with severe mitral valve disease, this case highlights the diagnostic challenges of differentiating between thrombi and tumors in the context of mitral valve disease. It illustrates the critical role of multimodal imaging in elucidating the anatomical and functional relationships within the heart, thereby guiding accurate diagnosis and effective treatment.

Complex decision making in a patient with lung cancer with incidentally found fast-growing atrial mass.

Atrial myxomas are typically found in the left atrium and are the most common among overall rare cardiac tumors. Herein, we describe the clinical course of a 72-year-old female with non-small cell lung adenocarcinoma found to have an atrial mass during an imaging for evaluation for lung cancer progression. Differentiating between distinct types of masses can pose a challenge to the treatment team especially in the setting of exiting malignancy. This case demonstrates the complex decision making involved in the diagnosis, and timing of intervention to remove atrial mass in patients with frailty and a fast-growing cardiac mass.

The Standard-Dose Heparin-Warfarin Remedy Partially Resolves Thrombi in the Right Superior Pulmonary Vein and Left Atrium and Ameliorates Type 2 Diabetes Mellitus.

Pulmonary vein thrombosis is common and underdiagnosed. Previously, we reported several cases of pulmonary vein thrombi (PVTs) using cardiac computed tomography (CT) and transesophageal echocardiography (TEE). We reported that warfarin and direct oral anticoagulants (DOACs) partially resolved PVTs; however, it is difficult to resolve all PVTs completely. Therefore, we evaluated the effects of standard-dose heparin-warfarin remedy on PVTs and left atrium (LA) thrombi using TEE and cardiac CT. A 64-year-old male with type 2 diabetes mellitus (T2DM) and hypertension was assessed for thrombi in the LA and pulmonary veins using TEE and 80-slice multidetector computed tomography (80-MDCT). After one month of standard-dose heparin-warfarin remedy, the patient's right superior pulmonary vein (RSPV) thrombi and expanded LA thrombi from the RSPV thrombi had partially resolved. The RSPV thrombi and the expanded LA thrombi from the RSPV thrombi were detected using cardiac CT and TEE; however, they were depicted as black areas on TEE. They periodically moved inward with the patient's heartbeats. Additionally, the standard-dose heparin-warfarin remedy ameliorated the patient's T2DM, and the remedy effect could be maintained for five months to some extent by administering a standard dose of warfarin. The standard-dose heparin-warfarin remedy can ameliorate not only T2DM but also diabetic complications such as diabetic nephropathy and gestational diabetes mellitus.

Percutaneous Debulking of a Large Mobile Mitral Valve Vegetation Using the Angiovac.

The Angiovac aspiration system has been used successfully for the removal of intravascular material or thrombus in the right-sided heart structures, vena cava, implantable cardiac defibrillator, or other devices. For infective endocarditis, it is reserved for the patients who warrant but are not good candidates for the surgery. The evidence regarding Angiovac aspiration of the infective endocarditis of the left-sided heart valves is scarce. The risk of complications, including thrombi fragmentation leading to systemic embolization, damage to the cardiac structures and tissue, and hemodynamic instability, precludes the widespread use of this procedure, especially for the left-sided lesions. We report a case of successful removal of the mitral valve endocarditis using the Angiovac aspiration technique under the TEE guidance. A SENTINEL™ cerebral protection system was used to prevent embolus migration and a venous rather than an arterial access was used for reperfusion.

Detection of occult thrombosis in individuals with Fontan circulation by cardiac MRI.

OBJECTIVE: Identifying thrombus formation in Fontan circulation has been highly variable, with reports between 17 and 33%. Initially, thrombus detection was mainly done through echocardiograms. Delayed-enhancement cardiac MRI is emerging as a more effective imaging technique for thrombus identification. This study aims to determine the prevalence of occult cardiac thrombosis in patients undergoing clinically indicated cardiac MRI. METHODS: A retrospective chart review of children and adults in the Duke University Hospital Fontan registry who underwent delayed-enhancement cardiac MRI. Individuals were excluded if they never received a delayed-enhancement cardiac MRI or had insufficient data. Demographic characteristics, native heart anatomy, cardiac MRI measurements, and thromboembolic events were collected for all patients. RESULTS: In total, 119 unique individuals met inclusion criteria with a total of 171 scans. The median age at Fontan procedure was 3 (interquartile range 1, 4) years. The majority of patients had dominant systemic right ventricle. Cardiac function was relatively unchanged from the first cardiac MRI to the third cardiac MRI. While 36.4% had a thrombotic event by history, only 0.5% (1 patient) had an intracardiac thrombus detected by delayed-enhancement cardiac MRI. CONCLUSIONS: Despite previous echocardiographic reports of high prevalence of occult thrombosis in patients with Fontan circulation, we found very low prevalence using delayed-enhancement cardiac MRI. As more individuals are reaching adulthood after requiring early Fontan procedures in childhood, further work is needed to develop thrombus-screening protocols as a part of anticoagulation management.

Dynamic Perviousness Predicts Revascularization Success in Acute Ischemic Stroke.

BACKGROUND: The predictive value of thrombus perviousness in acute ischemic stroke (AIS), as measured by computed tomography (CT), has been intensively studied with conflicting results. In this study, we investigate the predictive potential of the novel concept of dynamic perviousness using three-dimensional (3D) volumetric evaluation of occlusive thrombi. METHODS: The full thrombus volume in 65 patients with a hyperdense artery sign on non-contrast CT (NCCT), who underwent mechanical thrombectomy (MT), was segmented. Perviousness maps were computed voxel-wise for the entire thrombus volume as thrombus attenuation increase (TAI) between NCCT and CT angiography (CTA) as well as between CTA and late venous phase CT (CTV). Perviousness was analyzed for its association with NIHSS at admission, Thrombolysis In Cerebral Infarction (TICI) score, and number of MT passes. RESULTS: The mean late-uptake TAI of thrombi with NIHSS scores greater than 21 at admission was approximately 100% higher than for lower scored NIHSS (p between 0.05 and 0.005). Concerning revascularization results, thrombi requiring less than four MT passes had ca. 80% higher group mean late-uptake TAI than clots requiring four or more passes (p = 0.03), and thrombi with TICI score III had ca. 95% higher group mean late-uptake TAI than thrombi with TICI II (p = 0.03). Standard perviousness showed no significant correlation with MT results. CONCLUSION: Standard thrombus perviousness of 3D clot volume is not associated with revascularization results in AIS. In contrast, dynamic perviousness assessed with a voxel-wise characterization of 3D thrombi volume may be a better predictor of MT outcomes than standard perviousness.

Lipoprotein Glomerulopathy With Complete Resolution With Fenofibrate: Report of First Case From Pakistan.

Background: Lipoprotein glomerulopathy is an infrequent glomerular disorder that culminates in nephrotic syndrome and often progresses to kidney failure. Whereas most patients have been reported in Japan and China, limited reports have been documented outside these regions. This patient represents the first report of lipoprotein glomerulopathy in Pakistan. Case Presentation: A 25-year-old male patient, hypertensive for 2 years, presented with progressive body edema, frothy urine, and fatigue. Examination revealed elevated blood pressure, bilateral pedal edema, and positive shifting dullness. Laboratory results showed significant proteinuria and elevated cholesterol and triglyceride levels. Renal biopsy revealed enlarged glomeruli with a dilated capillary lumen filled with pale-staining mesh-like material "lipoprotein thrombi." Mild tubular atrophy and interstitial inflammation were observed. No interstitial fibrosis was evident. Electron microscopy detailed the lipoprotein thrombi with lipid granules and vacuoles of various sizes. A diagnosis of lipoprotein glomerulopathy was rendered. Treatment with fenofibrate, rosuvastatin, and captopril led to notable improvements in symptoms, blood pressure, and lipid levels during a 6-month follow-up. Subsequent biopsy showed complete resolution of the lipoprotein thrombi and a significant reduction in subendothelial granular densities. However, the flocculent subendothelial material persisted to some extent despite the complete resolution of lipoprotein thrombi. Conclusion: This report underscores the rarity of lipoprotein glomerulopathy in Pakistan and contributes valuable insights into its histopathologic features and global epidemiology. This unique instance aims to raise awareness among healthcare professionals, aiding in improved recognition of this rare entity. The favorable response to fenofibrate treatment underscores its effectiveness in managing lipoprotein glomerulopathy.

Left Atrial Diverticula Present in the Right Lower Pulmonary Vein Thrombus Attachment Area.

Left atrial diverticula (LADs) are thought to be associated with atrial fibrillation and an ischemic brain state. However, the mechanisms of LAD formation are unknown. Pulmonary vein thrombi (PVTs) can cause acute myocardial infarction (AMI) and ischemic stroke by releasing rather large particles. Additionally, PVTs can release much smaller particles, including neutrophil extracellular traps (NETs) and/or other components of NETs, such as DNA and histones. To treat these diseases, it may be crucial to know the specific traits of PVTs. However, these issues are not direct effects of PVTs on the left atrium (LA). It is unclear whether PVTs affect the LA directly. We checked the direct effects of PVTs on the LA using cardiac computed tomography (CT) and transesophageal echocardiography (TEE). The patient was a 73-year-old female with hypertension. TEE revealed extended LA thrombi from the right lower pulmonary vein, which were attached to the anterosuperior wall of the LA. Cardiac CT revealed the attaching area as a defect of enhancement and dimly revealed LAD with full thrombi on the attaching area. It was difficult to recognize the LAD at first; however, after one month of standard-dose heparin-warfarin treatment, the LAD was clearly detected using cardiac CT. LA thrombi could not be detected using cardiac CT.

Left Atrial Diverticula Supplied by the Anomalistic Branch of the Right Coronary Artery.

We have reported several cases of pulmonary vein thrombosis in elderly individuals with or without chest pain; pulmonary vein thrombosis is common in aged individuals and should be evaluated further. However, the properties and roles of pulmonary vein thrombi (PVTs) have not been determined. During infection, neutrophil extracellular traps (NETs) are produced to kill pathogens, and arterial thrombi (ATs) are produced in pulmonary veins to prevent pathogens from spreading to all organs. We reported that fine PVTs became larger PVTs and extended to the LA wall. PVTs can cause acute myocardial infarction (AMI) and ischemic stroke (IS) by releasing larger particles; therefore, the characteristics of PVTs need to be determined to prevent the occurrence of AMI and IS. PVTs can cause several diseases by releasing smaller particles, such as NETs, for which cumulative effects should be determined. PVTs and their effects on human health need to be studied to avoid missing the chances of treating patients with these diseases moderately. We reported that PVTs often extend to the left atrium (LA) and attach to the LA wall; however, the effects of attachment remain unclear. According to cardiac computed tomography (CT), left atrial diverticula (LADs) reportedly occur in 10%-50% of patients; however, the details of the LAD are unknown. Therefore, we examined the relationships among PVTs, LA thrombi, and LADs using cardiac CT and transesophageal echocardiography (TEE). The patient was a 65-year-old male with hypertension and severe palpitations. He had no history of AMI or IS. TEE revealed that the LA thrombi were attached to the anterior wall of the right lower pulmonary vein and that they were attached to the anterior wall of the LA. TEE revealed an LAD near the attachment area. Cardiac CT revealed an LAD without thrombi near the attachment area. Sagittal images from a cardiac CT scan revealed that a part of the attachment region in the LA was a dark line, where no blood flow was observed in the LA, and that there seemed to be the LAD on top of the dark line. The anomalistic branch of the right coronary artery (#1) connected around the top of the LAD.

The Desirable Effects of Edoxaban on Thrombi in the Left Atrium Are Seemingly Connected to Pulmonary Vein Thrombi.

Ischemic stroke (IS) causes various degrees of disability that sometimes induce social problems: therefore, preventing the occurrence and recurrence of IS is important. The recovery of motor function has been extensively studied. The characteristics of retrieved thrombi have become clearer; however, it is unclear what thrombi cause IS. Pulmonary vein thrombi (PVTs), such as those of the IS, can cause systemic thrombosis, by releasing several sizes of particles. PVTs are common but are underrated and can be detected via enhanced computed tomography (CT) and transesophageal echocardiography (TEE). PVTs often extend to the left atrium (LA) and can be mainly diagnosed using not enhanced CT but rather TEE. Extended LA thrombi are characterized by a lack of periodic movement with heartbeats. Direct oral anticoagulants (DOACs) are useful for preventing IS. We reported that rivaroxaban partially dissolved LA thrombi and PVTs using enhanced CT and TEE; however, the effects of edoxaban on LA thrombi and PVTs are unclear. We checked the images using enhanced CT and TEE and treated them with edoxaban. The patient was a 73-year-old female with easy fatigability. Edoxaban desirably affected the LA thrombi, and edoxaban partially dissolved the thrombi in the right lower pulmonary vein (RLPV). A decreased dose of edoxaban (15 mg, once a day) had similar effects on LA thrombi and RLPV thrombi, suggesting that this treatment could be useful for preventing IS.

Death due to sickle cell crisis: a case report.

Sickle cell disease (SCD) is the most common hereditary hemoglobinopathy worldwide. It results in characteristic acute and chronic findings on postmortem computed tomography (PMCT), macroscopic and microscopic examinations. While the diagnostic imaging and macroscopic features are not specific for SCD on their own, when coupled with microscopic features such as sickled erythrocytes and evidence of chronic venous congestion (i.e., Gamna-Gandy bodies), these clues can help alert forensic pathologists to the presence of SCD. Despite the prevalence of the disease and the constellation of findings alluded to above, SCD is not often explored in forensic pathology literature. This case demonstrates classic acute and chronic features of SCD on PMCT, macroscopic and microscopic examinations. It explores the pathophysiology leading to sudden and unexpected death in a person with SCD and possible pitfalls in attribution of cause of death.

The usefulness of contrast echocardiography in the evaluation of cardiac masses: a multicenter study.

BACKGROUND: Cardiac masses can encompass a variety of conditions, such as tumors, thrombi, vegetations, calcific lesions, and other rare diseases. Treatment and management of these types of cardiac masses differ considerably. Thus, accurately distinguishing among thrombi, benign tumors, and malignant tumors in the heart is of great importance. Contrast echocardiography (CE) has emerged as a promising technology. Although published guidelines suggest that CE can enhance image quality and assist in differentiating between benign and malignant lesions, most studies on CE diagnosis of cardiac masses are limited to case reports or retrospective/small-sample-sized prospective cohorts. This study aims to evaluate the diagnostic accuracy of CE in patients with suspected cardiac masses and address the insufficient evidence for differential diagnosis using CE. METHODS: Between April 2018 and July 2022, a prospective multicenter study was conducted, which included 145 consecutive patients suspected to have cardiac masses based on transthoracic echocardiography. All patients underwent CE examinations. The echocardiographic diagnosis relied on qualitative factors such as echogenicity, boundary, morphology of the base, mass perfusion, pericardial effusion, and motility as well as quantitative factors such as the area of the masses and the peak intensity ratio of the masses to adjacent myocardium (A1/A2). RESULTS: The final confirmed diagnoses were as follows: 2 patients had no cardiac mass, 4 patients had pseudomass, 43 patients had thrombus, 66 patients had benign tumors, and 30 patients had malignant tumors. The receiver operating characteristic (ROC) analysis indicated that an optimal A1/A2 cutoff value of 0.499 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.977, 97.9%, 90.7%, 95.9%, and 95.1%, respectively. The optimal A1/A2 cutoff value of 1.583 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.950, 93.3%, 93.9%, 87.5%, and 96.9%, respectively. CONCLUSIONS: Combined with qualitative and quantitative analyses, CE has the potential to accurately differentiate among different types of cardiac masses.

Pulmonary tumor embolism in a maintenance hemodialysis patient with hepatocellular carcinoma.

Patients with chronic kidney disease are already at an increased risk for pulmonary embolism, since loss of renal function rendered a procoagulant state. Further, malignant tumor is a well-established risk factor for pulmonary thromboembolism. Alternatively, occlusion of the pulmonary vasculature by tumor cells per se and associated thrombi may mimic thromboembolic disease. By comparison, however, report of pulmonary tumor embolism (PTE) in patients on maintenance hemodialysis (MHD) is exceedingly rare. A less vigilant clinician may have otherwise treated this situation as fluid overload or thromboembolic disorder. We herein described in an MHD patient such an unusual case of PTE, which was diagnosed by contrast-enhanced CT and PET/CT. As such, our work may expand the knowledge reserve of dialysis staffs about this rare complication of malignancy.

A computational investigation of occlusive arterial thrombosis.

The generation of occlusive thrombi in stenotic arteries involves the rapid deposition of millions of circulating platelets under high shear flow. The process is mediated by the formation of molecular bonds of several distinct types between platelets; the bonds capture the moving platelets and stabilize the growing thrombi under flow. We investigated the mechanisms behind occlusive thrombosis in arteries with a two-phase continuum model. The model explicitly tracks the formation and rupture of the two types of interplatelet bonds, the rates of which are coupled with the local flow conditions. The motion of platelets in the thrombi results from competition between the viscoelastic forces generated by the interplatelet bonds and the fluid drag. Our simulation results indicate that stable occlusive thrombi form only under specific combinations for the ranges of model parameters such as rates of bond formation and rupture, platelet activation time, and number of bonds required for platelet attachment.