Giant isolated intracardiac thrombus presenting as acute heart failure secondary to right ventricular outflow tract obstruction in a patient with renal carcinoma.

Right-sided intracardiac thrombi are potential causes of right ventricular (RV) failure, particularly when tricuspid or pulmonary obstruction occurs. In most cases, RV thrombus develops in patients with RV dysfunction and concomitant thrombosis in the systemic veins. However, RV thrombosis can rarely present as an isolated mass and despite preserved RV function, particularly in patients with thrombophilic states. In this report, we describe an unusual case of giant isolated RV thrombus presenting with acute RV failure secondary to dynamic RV outflow tract obstruction in a patient with renal carcinoma. Bedside echocardiography allowed a rapid assessment of the hemodynamic effects of the mass. The possibility of a thrombotic RV outflow obstruction should be considered in patients with acute RV failure, even in those with no evidence of thrombosis in the venous district. This may be particularly important in patients with prothrombotic states, where the effectiveness of routine thromboembolic prophylaxis could be reduced.

A Spiral in the Heart: Mitral Valve Endocarditis with Unusual Vegetation Shape Potentially Affecting Effectiveness of Antibiotic Therapy.

We report an unusual case of infective endocarditis (IE) in an 88-year-old woman, occurring on a prolapsing mitral valve and characterized by an atypical vegetation shape resembling a spiral-like appearance. After the patient refused surgical correction, persistent IE despite prolonged antibiotic therapy was observed, resulting in an ischemic stroke probably secondary to septic embolus. The importance of vegetation shape in the management of patients with IE was classically related to the increased risk of embolization associated with pedunculated, irregular, and multilobed masses. We hypothesize that the unusual spiral-like vegetation shape in our patient may have favored IE persistence by two mechanisms, namely, a decrease of the exposed vegetation surface with creation of an internal core where the penetration of antimicrobial agents was obstacled and the creation of blood turbulence within the vegetation preventing a prolonged contact with circulating antibiotics. These considerations suggest that vegetation shape might be considered of importance in patients with IE not only because of its classical association with embolization risk, but also because of its potential effect on the efficacy of antibiotic therapy.

Subclavian steal syndrome presenting as recurrent pulmonary oedema associated with acute left ventricular diastolic dysfunction.

Subclavian steal syndrome typically presents as angina in patients with internal mammary artery grafts. Atypical clinical presentations have been rarely described. We report an unusual case of subclavian steal syndrome presenting as pulmonary oedema with acute left ventricular diastolic dysfunction and preserved ejection fraction in a patient with internal mammary artery graft and severe stenosis of the proximal left subclavian artery. After successful angioplasty and stenting of subclavian artery, the patient remained asymptomatic for six months, but then experienced acute diastolic dysfunction and recurrent pulmonary oedema associated with critical subclavian in-stent restenosis with stent deformation. This report points out that, in patients with internal mammary-to-LAD grafts, subclavian steal syndrome may present as acute left ventricular diastolic dysfunction and pulmonary oedema even in the presence of normal ejection fraction.