array:25 [
  "pii" => "S0870255116000676"
  "issn" => "08702551"
  "doi" => "10.1016/j.repc.2015.09.027"
  "estado" => "S300"
  "fechaPublicacion" => "2016-04-01"
  "aid" => "791"
  "copyright" => "Sociedade Portuguesa de Cardiologia"
  "copyrightAnyo" => "2016"
  "documento" => "simple-article"
  "crossmark" => 1
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "crp"
  "cita" => "Rev Port Cardiol. 2016;35:233.e1-3"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 13615
    "formatos" => array:3 [
      "EPUB" => 211
      "HTML" => 12886
      "PDF" => 518
    ]
  ]
  "Traduccion" => array:1 [
    "en" => array:20 [
      "pii" => "S2174204916300034"
      "issn" => "21742049"
      "doi" => "10.1016/j.repce.2015.09.020"
      "estado" => "S300"
      "fechaPublicacion" => "2016-04-01"
      "aid" => "791"
      "copyright" => "Sociedade Portuguesa de Cardiologia"
      "documento" => "simple-article"
      "crossmark" => 1
      "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
      "subdocumento" => "crp"
      "cita" => "Rev Port Cardiol. 2016;35:233.e1-3"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 2762
        "formatos" => array:3 [
          "EPUB" => 165
          "HTML" => 2030
          "PDF" => 567
        ]
      ]
      "en" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
        "titulo" => "Intracardiac thrombus and Murphy&#39;s law&#58; Reflections on a clinical dilemma"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => array:2 [
          0 => "en"
          1 => "pt"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "233&#46;e1"
            "paginaFinal" => "233&#46;e3"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "pt" => array:1 [
            "titulo" => "Trombos intracard&#237;acos e a lei de Murphy&#58; reflex&#227;o sobre um dilema cl&#237;nico"
          ]
        ]
        "contieneResumen" => array:2 [
          "en" => true
          "pt" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "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" => 1941
                "Ancho" => 2668
                "Tamanyo" => 573578
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Transthoracic echocardiogram&#44; apical 4-chamber view in diastole&#44; showing apical LV thrombus&#59; &#40;B&#41; transthoracic echocardiogram&#44; apical 4-chamber view in systole&#44; showing the thrombus protruding into the LV cavity&#59; &#40;C&#41; transthoracic echocardiogram&#44; apical 3-chamber view&#44; showing the LV and LA thrombi&#59; &#40;D&#41; cerebral computed tomography&#44; displaying a large cerebral infarct&#59; &#40;E&#8211;G&#41; abdominal computed tomography with contrast&#44; showing splenic &#40;E&#41; and renal &#40;F&#41; infarcts and almost total occlusion of the infrarenal abdominal aorta &#40;G&#41;&#46; LA&#58; left atrial&#59; LV&#58; left ventricular&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Patr&#237;cia Rodrigues, Maria Jo&#227;o Sousa, Lu&#237;sa Caiado, Sofia Cabral, Ana Meireles, M&#225;rio Santos, Paulo Palma, Severo Torres"
            "autores" => array:8 [
              0 => array:2 [
                "nombre" => "Patr&#237;cia"
                "apellidos" => "Rodrigues"
              ]
              1 => array:2 [
                "nombre" => "Maria Jo&#227;o"
                "apellidos" => "Sousa"
              ]
              2 => array:2 [
                "nombre" => "Lu&#237;sa"
                "apellidos" => "Caiado"
              ]
              3 => array:2 [
                "nombre" => "Sofia"
                "apellidos" => "Cabral"
              ]
              4 => array:2 [
                "nombre" => "Ana"
                "apellidos" => "Meireles"
              ]
              5 => array:2 [
                "nombre" => "M&#225;rio"
                "apellidos" => "Santos"
              ]
              6 => array:2 [
                "nombre" => "Paulo"
                "apellidos" => "Palma"
              ]
              7 => array:2 [
                "nombre" => "Severo"
                "apellidos" => "Torres"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S0870255116000676"
          "doi" => "10.1016/j.repc.2015.09.027"
          "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/S0870255116000676?idApp=UINPBA00004E"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916300034?idApp=UINPBA00004E"
      "url" => "/21742049/0000003500000004/v2_201703300127/S2174204916300034/v2_201703300127/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S087025511600069X"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2015.07.014"
    "estado" => "S300"
    "fechaPublicacion" => "2016-04-01"
    "aid" => "793"
    "documento" => "simple-article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "crp"
    "cita" => "Rev Port Cardiol. 2016;35:235&#46;e1-4"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 2599
      "formatos" => array:3 [
        "EPUB" => 174
        "HTML" => 1965
        "PDF" => 460
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
      "titulo" => "Massive hemoptysis as an unusual complication of right heart catheterization&#58; Successful treatment with percutaneous stent"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "pt"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "235&#46;e1"
          "paginaFinal" => "235&#46;e4"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "Hemoptises massivas como complica&#231;&#227;o pouco habitual do cateterismo direito&#58; um tratamento bem-sucedido com <span class="elsevierStyleItalic">stent</span> percut&#226;neo"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "pt" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 821
              "Ancho" => 3001
              "Tamanyo" => 209181
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pulmonary angiogram confirming the presence and location of the pulmonary artery pseudoaneurysm &#40;arrow&#41;&#44; showing its extent&#58; &#40;A&#41; anteroposterior view&#44; with stent graft implantation &#40;arrow&#41; to treat the pseudoaneurysm&#59; &#40;B&#41; anteroposterior view&#44; showing an excellent result with unrestricted blood flow into the periphery when the bleeding had stopped &#40;arrow&#41;&#59; &#40;C&#41; anteroposterior view&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Filipa Mel&#227;o, Ricardo Lopes, Rui Andr&#233; Rodrigues, Domingos Magalh&#227;es, Paulo Vilares Morgado, Jo&#227;o Carlos Silva, Manuel Campelo, Maria J&#250;lia Maciel"
          "autores" => array:8 [
            0 => array:2 [
              "nombre" => "Filipa"
              "apellidos" => "Mel&#227;o"
            ]
            1 => array:2 [
              "nombre" => "Ricardo"
              "apellidos" => "Lopes"
            ]
            2 => array:2 [
              "nombre" => "Rui Andr&#233;"
              "apellidos" => "Rodrigues"
            ]
            3 => array:2 [
              "nombre" => "Domingos"
              "apellidos" => "Magalh&#227;es"
            ]
            4 => array:2 [
              "nombre" => "Paulo"
              "apellidos" => "Vilares Morgado"
            ]
            5 => array:2 [
              "nombre" => "Jo&#227;o Carlos"
              "apellidos" => "Silva"
            ]
            6 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "Campelo"
            ]
            7 => array:2 [
              "nombre" => "Maria J&#250;lia"
              "apellidos" => "Maciel"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2174204916300046"
        "doi" => "10.1016/j.repce.2015.07.020"
        "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/S2174204916300046?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511600069X?idApp=UINPBA00004E"
    "url" => "/08702551/0000003500000004/v1_201604010041/S087025511600069X/v1_201604010041/en/main.assets"
  ]
  "itemAnterior" => array:20 [
    "pii" => "S087025511500325X"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2015.09.013"
    "estado" => "S300"
    "fechaPublicacion" => "2016-04-01"
    "aid" => "746"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2016;35:229-31"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 3243
      "formatos" => array:3 [
        "EPUB" => 197
        "HTML" => 2467
        "PDF" => 579
      ]
    ]
    "pt" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Cardiologia baseada na evid&#234;ncia</span>"
      "titulo" => "<span class="elsevierStyleItalic">Cochrane Corner</span>&#58; uso do bal&#227;o intra&#8208;a&#243;rtico em doentes com enfarte agudo do mioc&#225;rdio complicado com choque cardiog&#233;nico"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => array:2 [
        0 => "pt"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "229"
          "paginaFinal" => "231"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Cochrane Corner&#58; Intra&#8208;aortic balloon pump in patients with cardiogenic shock following myocardial infarction"
        ]
      ]
      "contieneResumen" => array:2 [
        "pt" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figura 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 508
              "Ancho" => 3249
              "Tamanyo" => 123802
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Risco de morte a 30 dias com a utiliza&#231;&#227;o do BIA&#46; Adaptado de&#58; Unverzagt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a>&#46; BIA&#58; bal&#227;o intra&#8208;a&#243;rtico&#59; DAV&#58; dispositivos de assist&#234;ncia ventricular&#59; HR&#58; <span class="elsevierStyleItalic">hazard ratio</span>&#59; IC 95&#37;&#58; intervalo de confian&#231;a de 95&#37;&#59; RCT&#58; ensaios cl&#237;nicos controlados e aleatorizados&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Daniel Caldeira, H&#233;lder Pereira, Jo&#227;o Costa, Ant&#243;nio Vaz&#8208;Carneiro"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Daniel"
              "apellidos" => "Caldeira"
            ]
            1 => array:2 [
              "nombre" => "H&#233;lder"
              "apellidos" => "Pereira"
            ]
            2 => array:2 [
              "nombre" => "Jo&#227;o"
              "apellidos" => "Costa"
            ]
            3 => array:2 [
              "nombre" => "Ant&#243;nio"
              "apellidos" => "Vaz&#8208;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&#39;s law&#58; Reflections on a clinical dilemma"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "233&#46;e1"
        "paginaFinal" => "233&#46;e3"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Patr&#237;cia Rodrigues, Maria Jo&#227;o Sousa, Lu&#237;sa Caiado, Sofia Cabral, Ana Meireles, M&#225;rio Santos, Paulo Palma, Severo Torres"
        "autores" => array:8 [
          0 => array:4 [
            "nombre" => "Patr&#237;cia"
            "apellidos" => "Rodrigues"
            "email" => array:1 [
              0 => "pfdrodrigues&#64;gmail&#46;com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "Maria Jo&#227;o"
            "apellidos" => "Sousa"
          ]
          2 => array:2 [
            "nombre" => "Lu&#237;sa"
            "apellidos" => "Caiado"
          ]
          3 => array:2 [
            "nombre" => "Sofia"
            "apellidos" => "Cabral"
          ]
          4 => array:2 [
            "nombre" => "Ana"
            "apellidos" => "Meireles"
          ]
          5 => array:2 [
            "nombre" => "M&#225;rio"
            "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&#44; Centro Hospitalar do Porto&#44; Porto&#44; Portugal"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Trombos intracard&#237;acos e a lei de Murphy&#58; reflex&#227;o sobre um dilema cl&#237;nico"
      ]
    ]
    "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">&#40;A&#41; Transthoracic echocardiogram&#44; apical 4-chamber view in diastole&#44; showing apical LV thrombus&#59; &#40;B&#41; transthoracic echocardiogram&#44; apical 4-chamber view in systole&#44; showing the thrombus protruding into the LV cavity&#59; &#40;C&#41; transthoracic echocardiogram&#44; apical 3-chamber view&#44; showing the LV and LA thrombi&#59; &#40;D&#41; cerebral computed tomography&#44; displaying a large cerebral infarct&#59; &#40;E&#8211;G&#41; abdominal computed tomography with contrast&#44; showing splenic &#40;E&#41; and renal &#40;F&#41; infarcts and almost total occlusion of the infrarenal abdominal aorta &#40;G&#41;&#46; LA&#58; left atrial&#59; LV&#58; left ventricular&#46;</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&#44; a smoker&#44; with type 2 diabetes mellitus&#44; hypertension&#44; dyslipidemia&#44; stage 3 renal failure and atrial fibrillation &#40;AF&#41;&#46; He had been recently diagnosed with probable tachycardiomyopathy&#44; because of fluctuating degrees of left ventricular systolic dysfunction in the context of poorly controlled AF&#44; in the absence of coronary artery disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">He was admitted with rapid AF and decompensated heart failure&#46; In terms of AF treatment&#44; he was taking bisoprolol&#44; digoxin and warfarin&#44; but his international normalized ratio was subtherapeutic&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">He was started on parenteral anticoagulation&#44; but shortly after admission he developed left hemiparesis&#44; pain in the lower limbs and abdominal pain&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The echocardiogram showed moderate left ventricular &#40;LV&#41; systolic impairment and a massive mobile thrombus in the LV apex &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B&#41; and another in the left atrium &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Computed tomography confirmed multiple cerebral &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D&#41;&#44; splenic &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>E&#41; and renal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>F&#41; infarcts&#44; as well as an almost total occlusion of the infrarenal abdominal aorta &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>G&#41;&#44; distal to the origin of the inferior mesenteric artery&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was referred for emergent thrombectomy for removal of the aortic thrombus and continued anticoagulation&#44; with favorable recovery&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This is a catastrophic case of intracardiac thrombus with massive systemic emboli&#46; It is a reminder of the dangerous association between atrial fibrillation and left ventricular systolic impairment&#44; highlighting the importance of adequate anticoagulation in these patients&#46;</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&#44; even with anticoagulation treatment&#46; Surgical thrombectomy<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a> may be considered&#44; especially if there are recurrent emboli despite anticoagulation and if the thrombus remains large&#44; but it also carries a very high risk&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Some weeks later&#44; another patient was admitted to our center with a history of ischemic heart disease and decompensated heart failure&#46; She had a very large&#44; apparently pedunculated and protruding LV thrombus&#46; Medical and surgical treatment options were discussed&#44; but her surgical risk was felt to be very high and she was started on anticoagulation&#44; maintaining clinical stability&#46; After a week&#44; when she was about to be discharged&#44; a transthoracic echocardiogram was repeated&#44; which no longer showed any intracardiac thrombus&#46; A few hours later&#44; she suddenly died of a massive stroke&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion&#44; handling patients with a large intracardiac thrombus&#44; particularly when located in the left cardiac chambers and clearly fresh&#44; mobile and pedunculated&#44; is often problematic&#46; In these circumstances&#44; to start anticoagulation and hope for the best feels quite insufficient&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the few observational studies available to date&#44; 10&#8211;15&#37; of patients with an LV thrombus &#40;most of them after myocardial infarction&#41; suffered a significant embolic event&#44; especially in the first 3&#8211;4 months&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> and anticoagulation was associated with a significant reduction in the occurrence of embolization&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#44;5</span></a> However&#44; not all thrombi are the same&#46; In particular&#44; thrombus mobility and protrusion have been associated with a higher embolization risk&#44; of approximately 60&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Since large&#44; protruding&#44; fresh thrombi are relatively rare&#44; there are no studies that specifically address this problem&#46; 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&#44;7&#44;8</span></a> and perhaps this option should be considered more often&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Other options could also be explored&#44; such as the development of a percutaneous device to temporarily contain the thrombus in the apex and facilitate aspiration&#44; or some other option that increases the odds for a positive outcome&#46;</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&#46;</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&#46;</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&#46;</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&#46; The corresponding author is in possession of this document&#46;</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&#46;</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 ventr&#237;culo esquerdo"
            1 => "Emboliza&#231;&#227;o"
            2 => "Anticoagula&#231;&#227;o"
            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&#44; mobile and protruding apical thrombus&#46; In spite of anticoagulation treatment&#44; extensive and clearly defined systemic embolization occurred&#46;</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&#46;</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 disfun&#231;&#227;o sist&#243;lica ventricular esquerda e um trombo apical de grandes dimens&#245;es&#44; m&#243;vel e com protrus&#227;o para a cavidade ventricular&#46; Apesar do tratamento anticoagulante&#44; ocorreram v&#225;rios fen&#243;menos de emboliza&#231;&#227;o sist&#233;mica&#44; extensos e muito ilustrativos&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Discutimos a evid&#234;ncia atual sobre o tratamento de trombos intracard&#237;acos com alto risco de emboliza&#231;&#227;o sist&#233;mica e propomos uma reflex&#227;o sobre uma abordagem personalizada para evitar potenciais consequ&#234;ncias catastr&#243;ficas&#46;</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">&#40;A&#41; Transthoracic echocardiogram&#44; apical 4-chamber view in diastole&#44; showing apical LV thrombus&#59; &#40;B&#41; transthoracic echocardiogram&#44; apical 4-chamber view in systole&#44; showing the thrombus protruding into the LV cavity&#59; &#40;C&#41; transthoracic echocardiogram&#44; apical 3-chamber view&#44; showing the LV and LA thrombi&#59; &#40;D&#41; cerebral computed tomography&#44; displaying a large cerebral infarct&#59; &#40;E&#8211;G&#41; abdominal computed tomography with contrast&#44; showing splenic &#40;E&#41; and renal &#40;F&#41; infarcts and almost total occlusion of the infrarenal abdominal aorta &#40;G&#41;&#46; LA&#58; left atrial&#59; LV&#58; left ventricular&#46;</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&#46; Leor"
                            1 => "O&#46; Agranat"
                            2 => "R&#46; Mohr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Heart J"
                        "fecha" => "1990"
                        "volumen" => "119"
                        "paginaInicial" => "1199"
                        "paginaFinal" => "1201"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2330878"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surgical removal of a mobile&#44; pedunculated left ventricular thrombus&#58; report of 4 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46; Nili"
                            1 => "E&#46; Deviri"
                            2 => "R&#46; Jortner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Thorac Surg"
                        "fecha" => "1988"
                        "volumen" => "46"
                        "paginaInicial" => "396"
                        "paginaFinal" => "400"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3178348"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Increased embolic risk in patients with left ventricular thrombi"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;R&#46; Stratton"
                            1 => "A&#46;D&#46; Resnick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "1987"
                        "volumen" => "75"
                        "paginaInicial" => "1004"
                        "paginaFinal" => "1011"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3568301"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prospective evaluation by two-dimensional echocardiography"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Mural thrombi in myocardial infarctions"
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46;C&#46; Keating"
                            1 => "S&#46;A&#46; Gross"
                            2 => "R&#46;A&#46; Schlamowitz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "1983"
                        "volumen" => "74"
                        "paginaInicial" => "989"
                        "paginaFinal" => "995"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6859067"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Embolic potential&#44; prevention and management of mural thrombus complicating anterior myocardial infarction&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46;T&#46; Vaitkus"
                            1 => "E&#46;S&#46; 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&#46;M&#46; Haugland"
                            1 => "R&#46;W&#46; Asinger"
                            2 => "F&#46;L&#46; 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&#58; a case series"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46; Cousin"
                            1 => "M&#46; Scholfield"
                            2 => "C&#46; Faber"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Heart Lung Vessel"
                        "fecha" => "2014"
                        "volumen" => "6"
                        "paginaInicial" => "88"
                        "paginaFinal" => "91"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25024990"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Left ventricular thrombus and subsequent thromboembolism&#44; comparison of anticoagulation&#44; surgical removal&#44; and antiplatelet agents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46;M&#46; Lee"
                            1 => "J&#46;J&#46; Park"
                            2 => "H&#46;W&#46; Jung"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Atheroscler Thromb"
                        "fecha" => "2013"
                        "volumen" => "20"
                        "paginaInicial" => "73"
                        "paginaFinal" => "93"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22986555"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/08702551/0000003500000004/v1_201604010041/S0870255116000676/v1_201604010041/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "29263"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Casos Cl&#237;nicos"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003500000004/v1_201604010041/S0870255116000676/v1_201604010041/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116000676?idApp=UINPBA00004E"
]
Partilhar
Informação da revista
Vol. 35. Núm. 4.
Páginas 233.e1-233.e3 (abril 2016)
Partilhar
Partilhar
Baixar PDF
Mais opções do artigo
Visitas
17366
Vol. 35. Núm. 4.
Páginas 233.e1-233.e3 (abril 2016)
Case report
Open Access
Intracardiac thrombus and Murphy's law: Reflections on a clinical dilemma
Trombos intracardíacos e a lei de Murphy: reflexão sobre um dilema clínico
Visitas
17366
Patrícia Rodrigues
Autor para correspondência
pfdrodrigues@gmail.com

Corresponding author.
, Maria João Sousa, Luísa Caiado, Sofia Cabral, Ana Meireles, Mário Santos, Paulo Palma, Severo Torres
Cardiology Department, Centro Hospitalar do Porto, Porto, Portugal
Este item recebeu

Under a Creative Commons license
Informação do artigo
Resume
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Figuras (1)
Abstract

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.

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.

Keywords:
Left ventricular thrombus
Embolization
Anticoagulation
Thrombectomy
Resumo

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.

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.

Palavras-chave:
Trombo do ventrículo esquerdo
Embolização
Anticoagulação
Trombectomia
Texto Completo
Case report

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.

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.

He was started on parenteral anticoagulation, but shortly after admission he developed left hemiparesis, pain in the lower limbs and abdominal pain.

The echocardiogram showed moderate left ventricular (LV) systolic impairment and a massive mobile thrombus in the LV apex (Figure 1A and B) and another in the left atrium (Figure 1C).

Figure 1.

(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.

(0.41MB).

Computed tomography confirmed multiple cerebral (Figure 1D), splenic (Figure 1E) and renal (Figure 1F) infarcts, as well as an almost total occlusion of the infrarenal abdominal aorta (Figure 1G), distal to the origin of the inferior mesenteric artery.

He was referred for emergent thrombectomy for removal of the aortic thrombus and continued anticoagulation, with favorable recovery.

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.

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 thrombectomy1,2 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.

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.

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.

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,3 and anticoagulation was associated with a significant reduction in the occurrence of embolization.4,5 However, not all thrombi are the same. In particular, thrombus mobility and protrusion have been associated with a higher embolization risk, of approximately 60%.3,6

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 results2,7,8 and perhaps this option should be considered more often.

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.

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.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

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.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
J. Leor, O. Agranat, R. Mohr, et al.
Urgent surgical removal of a rapidly growing left ventricular thrombus following acute myocardial infarction.
Am Heart J, 119 (1990), pp. 1199-1201
[2]
M. Nili, E. Deviri, R. Jortner, et al.
Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases.
Ann Thorac Surg, 46 (1988), pp. 396-400
[3]
J.R. Stratton, A.D. Resnick.
Increased embolic risk in patients with left ventricular thrombi.
Circulation, 75 (1987), pp. 1004-1011
[4]
E.C. Keating, S.A. Gross, R.A. Schlamowitz, Mural thrombi in myocardial infarctions, et al.
Prospective evaluation by two-dimensional echocardiography.
Am J Med, 74 (1983), pp. 989-995
[5]
P.T. Vaitkus, E.S. Barnathan.
Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: a meta-analysis.
J Am Coll Cardiol, 22 (1993), pp. 1004-1009
[6]
J.M. Haugland, R.W. Asinger, F.L. Mikell, et al.
Embolic potential of left ventricular thrombi detected by two-dimensional echocardiography.
Circulation, 70 (1984), pp. 588-598
[7]
E. Cousin, M. Scholfield, C. Faber, et al.
Treatment options for patients with mobile left ventricular thrombus and ventricular dysfunction: a case series.
Heart Lung Vessel, 6 (2014), pp. 88-91
[8]
J.M. Lee, J.J. Park, H.W. Jung, et al.
Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents.
J Atheroscler Thromb, 20 (2013), pp. 73-93
Copyright © 2016. Sociedade Portuguesa de Cardiologia
Baixar PDF
Idiomas
Revista Portuguesa de Cardiologia
Opções de artigo
Ferramentas
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Ao assinalar que é «Profissional de Saúde», declara conhecer e aceitar que a responsável pelo tratamento dos dados pessoais dos utilizadores da página de internet da Revista Portuguesa de Cardiologia (RPC), é esta entidade, com sede no Campo Grande, n.º 28, 13.º, 1700-093 Lisboa, com os telefones 217 970 685 e 217 817 630, fax 217 931 095 e com o endereço de correio eletrónico revista@spc.pt. Declaro para todos os fins, que assumo inteira responsabilidade pela veracidade e exatidão da afirmação aqui fornecida.