Case report
Intracardiac thrombus and Murphy's law: Reflections on a clinical dilemma
Trombos intracardíacos e a lei de Murphy: reflexão sobre um dilema clínico
Patrícia Rodrigues
, Maria João Sousa, Luísa Caiado, Sofia Cabral, Ana Meireles, Mário Santos, Paulo Palma, Severo Torres
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Cardiology Department, Centro Hospitalar do Porto, Porto, Portugal
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Adaptado de: Unverzagt et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a>. BIA: balão intra‐aórtico; DAV: dispositivos de assistência ventricular; HR: <span class="elsevierStyleItalic">hazard ratio</span>; IC 95%: intervalo de confiança de 95%; RCT: ensaios clínicos controlados e aleatorizados.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniel Caldeira, Hélder Pereira, João Costa, António Vaz‐Carneiro" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Daniel" "apellidos" => "Caldeira" ] 1 => array:2 [ "nombre" => "Hélder" "apellidos" => "Pereira" ] 2 => array:2 [ "nombre" => "João" "apellidos" => "Costa" ] 3 => array:2 [ "nombre" => "António" "apellidos" => "Vaz‐Carneiro" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204916000635" "doi" => "10.1016/j.repce.2015.09.018" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000635?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511500325X?idApp=UINPBA00004E" "url" => "/08702551/0000003500000004/v1_201604010041/S087025511500325X/v1_201604010041/pt/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Intracardiac thrombus and Murphy's law: Reflections on a clinical dilemma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "233.e1" "paginaFinal" => "233.e3" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Patrícia Rodrigues, Maria João Sousa, Luísa Caiado, Sofia Cabral, Ana Meireles, Mário Santos, Paulo Palma, Severo Torres" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Patrícia" "apellidos" => "Rodrigues" "email" => array:1 [ 0 => "pfdrodrigues@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Maria João" "apellidos" => "Sousa" ] 2 => array:2 [ "nombre" => "Luísa" "apellidos" => "Caiado" ] 3 => array:2 [ "nombre" => "Sofia" "apellidos" => "Cabral" ] 4 => array:2 [ "nombre" => "Ana" "apellidos" => "Meireles" ] 5 => array:2 [ "nombre" => "Mário" "apellidos" => "Santos" ] 6 => array:2 [ "nombre" => "Paulo" "apellidos" => "Palma" ] 7 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, Centro Hospitalar do Porto, Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Trombos intracardíacos e a lei de Murphy: reflexão sobre um dilema clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1942 "Ancho" => 2667 "Tamanyo" => 434344 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Transthoracic echocardiogram, apical 4-chamber view in diastole, showing apical LV thrombus; (B) transthoracic echocardiogram, apical 4-chamber view in systole, showing the thrombus protruding into the LV cavity; (C) transthoracic echocardiogram, apical 3-chamber view, showing the LV and LA thrombi; (D) cerebral computed tomography, displaying a large cerebral infarct; (E–G) abdominal computed tomography with contrast, showing splenic (E) and renal (F) infarcts and almost total occlusion of the infrarenal abdominal aorta (G). LA: left atrial; LV: left ventricular.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 49-year-old male, a smoker, with type 2 diabetes mellitus, hypertension, dyslipidemia, stage 3 renal failure and atrial fibrillation (AF). He had been recently diagnosed with probable tachycardiomyopathy, because of fluctuating degrees of left ventricular systolic dysfunction in the context of poorly controlled AF, in the absence of coronary artery disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">He was admitted with rapid AF and decompensated heart failure. In terms of AF treatment, he was taking bisoprolol, digoxin and warfarin, but his international normalized ratio was subtherapeutic.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He was started on parenteral anticoagulation, but shortly after admission he developed left hemiparesis, pain in the lower limbs and abdominal pain.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The echocardiogram showed moderate left ventricular (LV) systolic impairment and a massive mobile thrombus in the LV apex (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B) and another in the left atrium (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Computed tomography confirmed multiple cerebral (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D), splenic (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>E) and renal (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>F) infarcts, as well as an almost total occlusion of the infrarenal abdominal aorta (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>G), distal to the origin of the inferior mesenteric artery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was referred for emergent thrombectomy for removal of the aortic thrombus and continued anticoagulation, with favorable recovery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This is a catastrophic case of intracardiac thrombus with massive systemic emboli. It is a reminder of the dangerous association between atrial fibrillation and left ventricular systolic impairment, highlighting the importance of adequate anticoagulation in these patients.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It also prompts reflection on the lack of treatment options available for patients when a large mobile protruding thrombus is already present and there is a substantial risk for systemic embolic phenomena, even with anticoagulation treatment. Surgical thrombectomy<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> may be considered, especially if there are recurrent emboli despite anticoagulation and if the thrombus remains large, but it also carries a very high risk.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Some weeks later, another patient was admitted to our center with a history of ischemic heart disease and decompensated heart failure. She had a very large, apparently pedunculated and protruding LV thrombus. Medical and surgical treatment options were discussed, but her surgical risk was felt to be very high and she was started on anticoagulation, maintaining clinical stability. After a week, when she was about to be discharged, a transthoracic echocardiogram was repeated, which no longer showed any intracardiac thrombus. A few hours later, she suddenly died of a massive stroke.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, handling patients with a large intracardiac thrombus, particularly when located in the left cardiac chambers and clearly fresh, mobile and pedunculated, is often problematic. In these circumstances, to start anticoagulation and hope for the best feels quite insufficient.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the few observational studies available to date, 10–15% of patients with an LV thrombus (most of them after myocardial infarction) suffered a significant embolic event, especially in the first 3–4 months,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> and anticoagulation was associated with a significant reduction in the occurrence of embolization.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,5</span></a> However, not all thrombi are the same. In particular, thrombus mobility and protrusion have been associated with a higher embolization risk, of approximately 60%.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Since large, protruding, fresh thrombi are relatively rare, there are no studies that specifically address this problem. The few published case reports and observational studies of thrombus with these characteristics that were treated with a surgical approach showed successful results<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,7,8</span></a> and perhaps this option should be considered more often.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Other options could also be explored, such as the development of a percutaneous device to temporarily contain the thrombus in the apex and facilitate aspiration, or some other option that increases the odds for a positive outcome.</p><p id="par0070" class="elsevierStylePara elsevierViewall">We hope that further research will be performed in this area and that it will be possible to offer a better treatment strategy for high-risk intracardiac thrombus.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ethical disclosures</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Protection of human and animal subjects</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Confidentiality of data</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Right to privacy and informed consent</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres624349" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec637797" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres624350" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec637796" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Right to privacy and informed consent" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-10" "fechaAceptado" => "2015-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec637797" "palabras" => array:4 [ 0 => "Left ventricular thrombus" 1 => "Embolization" 2 => "Anticoagulation" 3 => "Thrombectomy" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec637796" "palabras" => array:4 [ 0 => "Trombo do ventrículo esquerdo" 1 => "Embolização" 2 => "Anticoagulação" 3 => "Trombectomia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We discuss the case of a 49-year-old patient with left ventricular systolic dysfunction and a large, mobile and protruding apical thrombus. In spite of anticoagulation treatment, extensive and clearly defined systemic embolization occurred.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We discuss the current evidence on the treatment of intracardiac thrombus with high risk of systemic embolization and propose a tailored approach to avoid potential catastrophic consequences.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso de um doente de 49 anos com disfunção sistólica ventricular esquerda e um trombo apical de grandes dimensões, móvel e com protrusão para a cavidade ventricular. Apesar do tratamento anticoagulante, ocorreram vários fenómenos de embolização sistémica, extensos e muito ilustrativos.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Discutimos a evidência atual sobre o tratamento de trombos intracardíacos com alto risco de embolização sistémica e propomos uma reflexão sobre uma abordagem personalizada para evitar potenciais consequências catastróficas.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1942 "Ancho" => 2667 "Tamanyo" => 434344 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Transthoracic echocardiogram, apical 4-chamber view in diastole, showing apical LV thrombus; (B) transthoracic echocardiogram, apical 4-chamber view in systole, showing the thrombus protruding into the LV cavity; (C) transthoracic echocardiogram, apical 3-chamber view, showing the LV and LA thrombi; (D) cerebral computed tomography, displaying a large cerebral infarct; (E–G) abdominal computed tomography with contrast, showing splenic (E) and renal (F) infarcts and almost total occlusion of the infrarenal abdominal aorta (G). LA: left atrial; LV: left ventricular.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Urgent surgical removal of a rapidly growing left ventricular thrombus following acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Leor" 1 => "O. Agranat" 2 => "R. 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Barnathan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "1993" "volumen" => "22" "paginaInicial" => "1004" "paginaFinal" => "1009" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8409034" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Embolic potential of left ventricular thrombi detected by two-dimensional echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.M. Haugland" 1 => "R.W. Asinger" 2 => "F.L. Mikell" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1984" "volumen" => "70" "paginaInicial" => "588" "paginaFinal" => "598" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6478564" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0075" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment options for patients with mobile left ventricular thrombus and ventricular dysfunction: a case series" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Cousin" 1 => "M. Scholfield" 2 => "C. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
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| 2024 Outubro | 58 | 29 | 87 |
| 2024 Setembro | 103 | 21 | 124 |
| 2024 Agosto | 64 | 28 | 92 |
| 2024 Julho | 39 | 28 | 67 |
| 2024 Junho | 32 | 18 | 50 |
| 2024 Maio | 47 | 21 | 68 |
| 2024 Abril | 42 | 20 | 62 |
| 2024 Maro | 37 | 25 | 62 |
| 2024 Fevereiro | 42 | 25 | 67 |
| 2024 Janeiro | 31 | 24 | 55 |
| 2023 Dezembro | 41 | 27 | 68 |
| 2023 Novembro | 42 | 21 | 63 |
| 2023 Outubro | 28 | 14 | 42 |
| 2023 Setembro | 25 | 19 | 44 |
| 2023 Agosto | 27 | 31 | 58 |
| 2023 Julho | 35 | 11 | 46 |
| 2023 Junho | 53 | 15 | 68 |
| 2023 Maio | 46 | 21 | 67 |
| 2023 Abril | 24 | 4 | 28 |
| 2023 Maro | 39 | 19 | 58 |
| 2023 Fevereiro | 33 | 24 | 57 |
| 2023 Janeiro | 36 | 10 | 46 |
| 2022 Dezembro | 28 | 17 | 45 |
| 2022 Novembro | 35 | 20 | 55 |
| 2022 Outubro | 47 | 18 | 65 |
| 2022 Setembro | 28 | 35 | 63 |
| 2022 Agosto | 40 | 35 | 75 |
| 2022 Julho | 44 | 37 | 81 |
| 2022 Junho | 31 | 25 | 56 |
| 2022 Maio | 36 | 29 | 65 |
| 2022 Abril | 49 | 35 | 84 |
| 2022 Maro | 28 | 31 | 59 |
| 2022 Fevereiro | 29 | 35 | 64 |
| 2022 Janeiro | 33 | 40 | 73 |
| 2021 Dezembro | 31 | 29 | 60 |
| 2021 Novembro | 47 | 35 | 82 |
| 2021 Outubro | 46 | 44 | 90 |
| 2021 Setembro | 39 | 33 | 72 |
| 2021 Agosto | 47 | 33 | 80 |
| 2021 Julho | 33 | 23 | 56 |
| 2021 Junho | 29 | 23 | 52 |
| 2021 Maio | 33 | 31 | 64 |
| 2021 Abril | 88 | 37 | 125 |
| 2021 Maro | 95 | 29 | 124 |
| 2021 Fevereiro | 58 | 18 | 76 |
| 2021 Janeiro | 46 | 17 | 63 |
| 2020 Dezembro | 70 | 14 | 84 |
| 2020 Novembro | 53 | 15 | 68 |
| 2020 Outubro | 37 | 13 | 50 |
| 2020 Setembro | 79 | 23 | 102 |
| 2020 Agosto | 47 | 6 | 53 |
| 2020 Julho | 59 | 16 | 75 |
| 2020 Junho | 78 | 15 | 93 |
| 2020 Maio | 85 | 8 | 93 |
| 2020 Abril | 70 | 11 | 81 |
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| 2019 Novembro | 634 | 16 | 650 |
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| 2019 Janeiro | 91 | 7 | 98 |
| 2018 Dezembro | 48 | 12 | 60 |
| 2018 Novembro | 95 | 10 | 105 |
| 2018 Outubro | 149 | 14 | 163 |
| 2018 Setembro | 53 | 13 | 66 |
| 2018 Agosto | 35 | 18 | 53 |
| 2018 Julho | 34 | 5 | 39 |
| 2018 Junho | 43 | 13 | 56 |
| 2018 Maio | 64 | 11 | 75 |
| 2018 Abril | 37 | 10 | 47 |
| 2018 Maro | 78 | 10 | 88 |
| 2018 Fevereiro | 43 | 5 | 48 |
| 2018 Janeiro | 65 | 3 | 68 |
| 2017 Dezembro | 78 | 15 | 93 |
| 2017 Novembro | 60 | 14 | 74 |
| 2017 Outubro | 26 | 14 | 40 |
| 2017 Setembro | 23 | 7 | 30 |
| 2017 Agosto | 34 | 13 | 47 |
| 2017 Julho | 23 | 4 | 27 |
| 2017 Junho | 37 | 16 | 53 |
| 2017 Maio | 32 | 10 | 42 |
| 2017 Abril | 31 | 4 | 35 |
| 2017 Maro | 27 | 11 | 38 |
| 2017 Fevereiro | 17 | 2 | 19 |
| 2017 Janeiro | 19 | 3 | 22 |
| 2016 Dezembro | 32 | 6 | 38 |
| 2016 Novembro | 34 | 6 | 40 |
| 2016 Outubro | 36 | 5 | 41 |
| 2016 Setembro | 15 | 8 | 23 |
| 2016 Agosto | 21 | 10 | 31 |
| 2016 Julho | 26 | 7 | 33 |
| 2016 Junho | 3 | 13 | 16 |
| 2016 Maio | 6 | 0 | 6 |
| 2016 Abril | 113 | 42 | 155 |
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