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International Journal of Cardiology Dec 2017Despite optimal oral anticoagulation with vitamin K antagonist, left atrial (LA) thrombus could be detected in the left appendage (LAA) in >2% of patients with atrial... (Observational Study)
Observational Study
AIMS
Despite optimal oral anticoagulation with vitamin K antagonist, left atrial (LA) thrombus could be detected in the left appendage (LAA) in >2% of patients with atrial fibrillation (AF) and CHADS-VASc score≥1 but few data are available for patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). We evaluated the occurrence and predictors of LA thrombi by means of transesophageal echocardiography (TOE) in consecutive patients with non-valvular AF who received for at least 3weeks Apixaban, Dabigatran, or Rivaroxaban.
METHODS
This study included 414 consecutive patients (male 252, 60.6%, mean age 67.3years) referred to our Centers for catheter ablation of AF (n=220, 53.1%) or scheduled electrical cardioversion (n=194, 46.9%). Patients were on Dabigatran (n=160), Rivaroxaban (n=150) or Apixaban (n=104). TOE was performed in all cases within 12h prior to ablation or cardioversion.
RESULTS
Preprocedural TOE revealed LA thrombus in 15/414 patients (3.6%), all located in the LAA (Apixaban 3/104 2.9%, Dabigatran 5/160 3.1%, and Rivaroxaban 7/150 4.7%, p=0.69). Of these, 14 patients had persistent AF. Patients with LAA thrombus had a mean CHADS-VASc score of 3 (3-4). Higher CHADS-VASc score (p=0.02), but not the type of NOAC, significantly predicted the presence of LA thrombus.
CONCLUSION
The incidence of LAA thrombus in a cohort of patients anticoagulated with NOACs is low but not negligible, in any case similar among the 3 drugs. Preprocedural TOE should be considered in patients with a CHADS-VASc score>3.
Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Cohort Studies; Echocardiography, Transesophageal; Female; Heart Atria; Heart Diseases; Humans; Incidence; Male; Middle Aged; Predictive Value of Tests; Retrospective Studies; Thrombosis
PubMed: 29121724
DOI: 10.1016/j.ijcard.2017.07.048 -
JACC. Clinical Electrophysiology Jan 2017
Topics: Atrial Appendage; Humans; Septal Occluder Device; Thrombosis
PubMed: 29759699
DOI: 10.1016/j.jacep.2016.07.003 -
Journal of the American College of... Feb 2013We sought to assess the effect of atrial fibrillation (AF) on atrial thrombogenesis in humans by determining the impact of rate and rhythm.
OBJECTIVES
We sought to assess the effect of atrial fibrillation (AF) on atrial thrombogenesis in humans by determining the impact of rate and rhythm.
BACKGROUND
Although AF is known to increase the risk of thromboembolic stroke from the left atrium (LA), the exact mechanisms remain poorly understood.
METHODS
We studied 55 patients with AF who underwent catheter ablation while in sinus rhythm; 20 patients were induced into AF, 20 patients were atrial paced at 150 beats/min, and 15 were control patients. Blood samples were taken from the LA, right atrium, and femoral vein at baseline and at 15 min in all 3 groups. Platelet activation (P-selectin) was measured by flow cytometry. Thrombin generation (thrombin-antithrombin [TAT] complex), endothelial dysfunction (asymmetric dimethylarginine [ADMA]), and platelet-derived inflammation (soluble CD40 ligand [sCD40L]) were measured using enzyme-linked immunosorbent assay.
RESULTS
Platelet activation increased significantly in both the AF (p < 0.001) and pacing (p < 0.05) groups, but decreased in control patients (p < 0.001). Thrombin generation increased specifically in the LA compared with the periphery in both the AF (p < 0.01) and pacing (p < 0.01) groups, but decreased in control patients (p < 0.001). With AF, ADMA (p < 0.01) and sCD40L (p < 0.001) levels increased significantly at all sites, but were unchanged with pacing (ADMA, p = 0.5; sCD40L, p = 0.8) or in control patients (ADMA, p = 0.6; sCD40L, p = 0.9).
CONCLUSIONS
Rapid atrial rates and AF in humans both result in increased platelet activation and thrombin generation. Prothrombotic activation occurs to a greater extent in the human LA compared with systemic circulation. AF additionally induces endothelial dysfunction and inflammation. These findings suggest that although rapid atrial rates increase the thrombogenic risk, AF may further potentiate this risk.
Topics: Aged; Antithrombin III; Arginine; Atrial Fibrillation; CD40 Ligand; Catheter Ablation; Enzyme Inhibitors; Enzyme-Linked Immunosorbent Assay; Female; Heart Atria; Heart Rate; Humans; Male; Middle Aged; P-Selectin; Peptide Hydrolases; Platelet Activation; Risk Assessment; Risk Factors; Statistics as Topic; Stroke; Thrombosis
PubMed: 23333141
DOI: 10.1016/j.jacc.2012.11.046 -
Acta Neurochirurgica Feb 2021Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the...
BACKGROUND
Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances.
METHODS
We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution.
RESULTS
We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved.
CONCLUSION
Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting.
Topics: Arachnoid Cysts; Cardiac Catheters; Central Venous Catheters; Device Removal; Endovascular Procedures; Female; Heart Atria; Humans; Hydrocephalus; Male; Middle Aged; Retrospective Studies; Thromboembolism; Upper Extremity Deep Vein Thrombosis; Ventriculoperitoneal Shunt
PubMed: 33330950
DOI: 10.1007/s00701-020-04675-1 -
Journal of Thrombosis and Thrombolysis Jan 2021Studies using whole blood platelet aggregometry as a laboratory research tool, provided important insights into the mechanism and modulators of platelet aggregation.... (Review)
Review
Studies using whole blood platelet aggregometry as a laboratory research tool, provided important insights into the mechanism and modulators of platelet aggregation. Subsequently, a number of point-of-care (POC) platelet function tests (PFTs) were developed for clinical use, based on the concept that an individual's thrombotic profile could be assessed in vitro by assessing the response to stimulation of platelet aggregation by specific, usually solo agonists such as adenosine diphosphate (ADP), collagen and thrombin. However, adjusting antiplatelet medication in order to improve the results of such POC PFTs has not translated into a meaningful reduction in cardiovascular events, which may be attributable to important differences between the POC PFT techniques and in vivo conditions, including patient-to-patient variability. Important limitations of most tests include the use of citrate-anticoagulated blood. Citrate directly and irreversibly diminishes platelet function and even after recalcification, it may result in altered platelet aggregation in response to ADP, epinephrine or collagen, and interfere with thrombin generation from activated platelets. Furthermore, most tests do not employ flowing blood and therefore do not assess the effect of high shear forces on platelets that initiate, propagate and stabilize arterial thrombi. Finally, the effect of endogenous thrombolysis, due to fibrinolysis and dislodgement, which ultimately determines the outcome of a thrombotic stimulus, is mostly not assessed. In order to accurately reflect an individual's predisposition to arterial thrombosis, future tests of thrombotic status which overcome these limitations should be used, to improve cardiovascular risk prediction and to guide pharmacotherapy.
Topics: Animals; Blood Coagulation; Blood Platelets; Heart Atria; Humans; Platelet Aggregation; Platelet Function Tests; Point-of-Care Testing; Thrombosis
PubMed: 32529549
DOI: 10.1007/s11239-020-02170-z -
JACC. Clinical Electrophysiology Dec 2019This study aimed to investigate the prevalence and management of left atrial (LA) thrombi detected by transesophageal echocardiography (TEE) in patients with atrial...
OBJECTIVES
This study aimed to investigate the prevalence and management of left atrial (LA) thrombi detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation undergoing pulmonary vein isolation (PVI).
BACKGROUND
Little data are available on LA thrombi before PVI.
METHODS
All patients scheduled for PVI between April 2010 and April 2018 undergoing pre-procedural TEE were analyzed. Management of LA thrombus was at the discretion of the treating physician.
RESULTS
In this study, 1,753 pre-procedural TEE from 1,358 patients (mean age 61 ± 10 years, 28% female) were included. Anticoagulation was used in 86% of all TEE (51% with direct oral anticoagulants [DOAC], 35% with vitamin K antagonists [VKA]). Thrombi were found in 11 TEE (0.6%), all in the LA appendage. Of the 11 patients with a thrombus, 5 (46%) had paroxysmal atrial fibrillation, 2 (18%) had a CHADS-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) score of 1, and 5 (46%) were in sinus rhythm at the time of TEE. Of the 8 patients (72%) on anticoagulation therapy, 5 were treated with DOAC and 3 with VKA. Starting anticoagulation (n = 3), switching to VKA with a target international normalized ratio of 2.5 to 3 (n = 3), or switching to a DOAC (n = 1) or a different DOAC (n = 4) resulted in thrombus resolution in 9 of 11 patients (82%).
CONCLUSIONS
In patients with atrial fibrillation scheduled for PVI, LA thrombi are rare and present in <1%. Thrombi were found in patients on VKA and DOAC, in low-risk patients, and despite sinus rhythm. Thrombus resolution was achieved in the majority of patients by changing the anticoagulation regimen.
Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Catheter Ablation; Echocardiography, Transesophageal; Female; Heart Atria; Humans; Male; Middle Aged; Prevalence; Pulmonary Veins; Retrospective Studies; Thrombosis
PubMed: 31857039
DOI: 10.1016/j.jacep.2019.09.003 -
Kardiologia Polska 2018
Review
Topics: Atrial Fibrillation; Coronary Thrombosis; Female; Heart Atria; Heart Diseases; Humans; Male; Stroke
PubMed: 29131288
DOI: 10.5603/KP.a2017.0212 -
Medicine Dec 2021Hepatocellular carcinoma (HCC) is the fourth most common cause of cancer-related deaths and the sixth most commonly diagnosed cancer globally. Interdisciplinary and... (Review)
Review
Favorable response to multimodal treatment in hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus and left adrenal gland metastasis: A case report and literature review.
RATIONALE
Hepatocellular carcinoma (HCC) is the fourth most common cause of cancer-related deaths and the sixth most commonly diagnosed cancer globally. Interdisciplinary and multimodal treatment strategies are essential for a successful therapy in HCC. Established therapies for HCC treatment include surgical resection, liver transplantation, local ablative therapies, transarterial chemoembolization (TACE), tyrosine kinase inhibitors (TKIs), immunotherapy, and radiotherapy (RT).
PATIENT CONCERNS
A 52-year-old male patient did an ultrasound scan and found a large mass within the right lobe of the liver and gallstones in December 2018. He had a history of chronic hepatitis C virus infection (30 years) and was treated with sofosbuvir (400 mg, q.d.) for 1 year. The patient never had any symptoms of gallstones. Enhanced abdominal computed tomography of this patient showed a heterogeneous irregular mass with the largest measurement of up to 13.7 × 11.1 cm in size in the right lobe of the liver, meanwhile also had inferior vena cava (IVC) tumor thrombus, right atrial (RA) tumor thrombus, and left adrenal gland metastasis. The laboratory test data revealed that the serum tumor marker α-fetoprotein was 2.63 ng/mL, cancer antigen 19-9 (CA 19-9) was 34.40 U/mL, and protein induced by Vitamin K absence was 391.94 mAU/mL.
DIAGNOSIS
HCC with IVC tumor thrombus, RA tumor thrombus, and left adrenal gland metastasis, and gallstones.
INTERVENTIONS
He was hospitalized and received TACE treatment, oral TKIs, intravenous drip programmed cell death-1 (PD-1) inhibitor and RT.
OUTCOMES
The patient showed a favorable response after consecutive treatment with TACE, TKIs, PD-1 inhibitor, and RT. Until now, the patient has survived 34 months since the diagnosis of the disease.
LESSONS
Our case suggests that TACE combined with TKIs, PD-1 inhibitor, and RT may be a suitable treatment option for advanced HCC patients with IVC tumor thrombus and/or RA tumor thrombus, and/or adrenal gland metastasis.
Topics: Adrenal Gland Neoplasms; Carcinoma, Hepatocellular; Chemoembolization, Therapeutic; Combined Modality Therapy; Heart Atria; Hepatectomy; Humans; Immune Checkpoint Inhibitors; Liver Neoplasms; Male; Middle Aged; Thrombectomy; Thrombosis; Vena Cava, Inferior; Venous Thrombosis
PubMed: 34889243
DOI: 10.1097/MD.0000000000027987 -
Chinese Medical Journal Jan 2018
Topics: Heart Atria; Humans; Rupture, Spontaneous; Thrombosis
PubMed: 29336375
DOI: 10.4103/0366-6999.222329 -
Heart (British Cardiac Society) May 1997To evaluate the role of haemostatic and haemodynamic variables in left atrial thrombosis in non-rheumatic atrial fibrillation.
OBJECTIVE
To evaluate the role of haemostatic and haemodynamic variables in left atrial thrombosis in non-rheumatic atrial fibrillation.
DESIGN
Case-control study.
SUBJECTS
One hundred and nine patients with non-rheumatic atrial fibrillation.
INTERVENTIONS
Peak blood velocity measured at three sites in the left atrium. Venous blood sampled for coagulant proteins and markers of haemostatic activation.
MAIN OUTCOME MEASURES
Presence of left atrial thrombus and spontaneous echo contrast at transoesophageal echocardiography.
RESULTS
Left atrial thrombus was identified in 19 patients (18%), 16 of whom had spontaneous echo contrast. Patients with thrombus had reduced peak left atrial appendage velocity compared with those without (0.17 v 0.26 m/s; P < 0.001), but no significant reductions in peak mid-left atrial or mitral valve outflow velocity. Patients with thrombus had increased plasma markers of platelet activation-beta thromboglobulin (56.8 v 30.4 IU/ml; P < 0.001) and platelet factor 4 (6.1 v 3.5 IU/ml; P < 0.01)-and of thrombogenesis: thrombin-antithrombin complexes (5.59 v 3.06 micrograms/ml; P < 0.001) and D-dimers (479 v 298 ng/ml; P < 0.01). von Willebrand factor was also increased (1.81 v 1.52 IU/ml; P < 0.05). A multiple logistic regression model identified left atrial appendage velocity (P = 0.001), beta thromboglobulin (P = 0.002), and von Willebrand factor (P = 0.04) as the independent associates of left atrial thrombosis, ahead of the presence of spontaneous echo contrast.
CONCLUSIONS
Haemostatic and haemodynamic abnormalities are associated with left atrial thrombus in non-rheumatic atrial fibrillation, and may help stratify thromboembolic risk.
Topics: Aged; Antithrombin III; Atrial Fibrillation; Biomarkers; Blood Flow Velocity; Case-Control Studies; Echocardiography, Transesophageal; Female; Fibrin Fibrinogen Degradation Products; Heart Atria; Heart Diseases; Humans; Male; Peptide Hydrolases; Platelet Factor 4; Thrombosis; beta-Thromboglobulin; von Willebrand Factor
PubMed: 9196408
DOI: 10.1136/hrt.77.5.407