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Resolution of Large Intra-Aortic Thrombus Following Anticoagulation Therapy
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Resolution of Large Intra-Aortic Thrombus Following Anticoagulation Therapy Anand P. Iyer, MCh ∗ , Dinesh Sadasivan, MCh, Umar Kamal, MBBS and Sanjay Sharma, FRACS Department of Cardiothoracic Surgery, Fremantle Hospital, Alma Street, Fremantle, WA, Australia
A 49-year-old lady presented with severe abdominal pain. She was haemodynamically stable. A CT scan of abdomen was taken, which revealed splenic infarcts. An echocardiography was done which revealed intra-aortic thrombus in the descending thoracic aorta. She was negative for hypercoagulopathic disorders. A MRI showed a large floating thrombus in descending thoracic aorta measuring 10 cm in size and arising from the site of attachment of ligamentum arteriosum (Fig. 1). Since she had no other symptoms and was very stable it was decided to go ahead with conservative management. She was anticoagulated with heparin followed by warfarin to maintain an INR of 3–4. One and 6 months after anticoagulation MRI were undertaken. The first one on the left shows some resolution of the thrombus and the second MRI showed almost complete resolution of thrombus (Fig. 2). She is well and asymptomatic two years after anticoagulation. Floating intra-aortic thrombus is rare and may cause severe central and peripheral thromboembolic complications.1 Atherosclerotic plaques, hypercoagulable conditions, cancer, pregnancy and very rarely insertion site of ductus arteriosus may contribute to intra-aortic thrombus formation. No standard approach exists for these unusual cases. Both surgical and thrombolytic modalities are advocated with favourable results.2,3 Thrombolysis is attempted initially and if there is no resolution or if contraindicated surgery is recommended.
Figure 1. MRI showing a large floating intraaortic thrombus measuring 10 mm and arising from the site of attachment of ligamentum arteriosum.
Received 16 July 2007; accepted 12 September 2007; available online 3 December 2007 ∗
Corresponding author. Tel.: +61 8 94313333. E-mail address: [email protected] (A.P. Iyer).
1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.09.006
50
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Heart, Lung and Circulation 2009;18:49–51
IMAGES
Figure 2. MRI done 1 and 6 months after anticoagulation showing partial resolution in 1 month and almost complete resolution in 6 months.
References 1. Bruno P, Massetti M, Babatasi G, Khayat A. Catastophic consequences of a free floating thrombus in ascending aorta. Eur J Cardiothorac Surg 2001;19:99–101. 2. Hausmann D, Gulba D, Bargheer K, Neidermeyer J, Comess KA, Daniel WG. Successful thrombolysis of an aortic-arch
thrombus in a patient after mesentric embolism. N Engl J Med 1992;327:500–1. 3. Sodian R, Bauer M, Weng Yu-Guo, Siniawski H, Koster A, Hetzer R. Floating nonocclusive thrombus in the ascending aorta. Ann Thorac Surg 2002;74:588–90.
Quadricuspid Aortic Valve: A Rare Clinical Entity Pankaj Saxena, MCh, DNB ∗ , Igor E. Konstantinov, MD, PhD, Stuart Downie, MBBS and Mark A.J. Newman, FRACS Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
A
35-year-old man presented to the Emergency Department with increasing chest tightness, palpitations and discomfort of recent onset. There was a significant worsening of symptoms over a week before presentation. On physical examination, the patient had clinical features suggestive of severe aortic regurgitation. The admission ECG showed T-wave inversions in inferior leads, which resolved within 12 h following admission to the hospital. Electrocardiogram (ECG) demonstrated the presence of left ventricular hypertrophy. Transthoracic echocardiography showed a quadricuspid aortic valve with cusp prolapse (Fig. 1) and severe aortic regurgitation (AR). Overall left ventricular function was normal.
Received 16 April 2007; accepted 27 June 2007; available online 4 September 2007 ∗
Corresponding author. Tel.: +61 8 93463333. E-mail address: [email protected] (P. Saxena).
Patient was stabilised medically and underwent aortic valve replacement with 25 mm St Jude valve. Cardiopulmonary bypass was used with systemic hypothermia to 28 ◦ C and myocardial protection using retrograde cold blood cardioplegia with topical hypothermia. Aortic valve at the time of surgery was found to have three large cusps and a small accessory noncoronary cusp (Figs. 2 and 3). Aortic root was normal. Patient made an uncomplicated recovery and was discharged home on day 11. The patient was symptom free and in good health at 1 year of follow up.
Discussion Quadricuspid aortic valve is a rare cause of aortic valve disease with a reported incidence of 0.008–0.033%.1,2 The condition predominantly causes aortic insufficiency. Symptomatic patients with quadricuspid aortic valve and severe AR should be treated with aortic valve replacement. 1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.06.525
Images
Resolution of Large Intra-Aortic Thrombus Following Anticoagulation Therapy Anand P. Iyer, MCh ∗ , Dinesh Sadasivan, MCh, Umar Kamal, MBBS and Sanjay Sharma, FRACS Department of Cardiothoracic Surgery, Fremantle Hospital, Alma Street, Fremantle, WA, Australia
A 49-year-old lady presented with severe abdominal pain. She was haemodynamically stable. A CT scan of abdomen was taken, which revealed splenic infarcts. An echocardiography was done which revealed intra-aortic thrombus in the descending thoracic aorta. She was negative for hypercoagulopathic disorders. A MRI showed a large floating thrombus in descending thoracic aorta measuring 10 cm in size and arising from the site of attachment of ligamentum arteriosum (Fig. 1). Since she had no other symptoms and was very stable it was decided to go ahead with conservative management. She was anticoagulated with heparin followed by warfarin to maintain an INR of 3–4. One and 6 months after anticoagulation MRI were undertaken. The first one on the left shows some resolution of the thrombus and the second MRI showed almost complete resolution of thrombus (Fig. 2). She is well and asymptomatic two years after anticoagulation. Floating intra-aortic thrombus is rare and may cause severe central and peripheral thromboembolic complications.1 Atherosclerotic plaques, hypercoagulable conditions, cancer, pregnancy and very rarely insertion site of ductus arteriosus may contribute to intra-aortic thrombus formation. No standard approach exists for these unusual cases. Both surgical and thrombolytic modalities are advocated with favourable results.2,3 Thrombolysis is attempted initially and if there is no resolution or if contraindicated surgery is recommended.
Figure 1. MRI showing a large floating intraaortic thrombus measuring 10 mm and arising from the site of attachment of ligamentum arteriosum.
Received 16 July 2007; accepted 12 September 2007; available online 3 December 2007 ∗
Corresponding author. Tel.: +61 8 94313333. E-mail address: [email protected] (A.P. Iyer).
1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.09.006
50
Images
Heart, Lung and Circulation 2009;18:49–51
IMAGES
Figure 2. MRI done 1 and 6 months after anticoagulation showing partial resolution in 1 month and almost complete resolution in 6 months.
References 1. Bruno P, Massetti M, Babatasi G, Khayat A. Catastophic consequences of a free floating thrombus in ascending aorta. Eur J Cardiothorac Surg 2001;19:99–101. 2. Hausmann D, Gulba D, Bargheer K, Neidermeyer J, Comess KA, Daniel WG. Successful thrombolysis of an aortic-arch
thrombus in a patient after mesentric embolism. N Engl J Med 1992;327:500–1. 3. Sodian R, Bauer M, Weng Yu-Guo, Siniawski H, Koster A, Hetzer R. Floating nonocclusive thrombus in the ascending aorta. Ann Thorac Surg 2002;74:588–90.
Quadricuspid Aortic Valve: A Rare Clinical Entity Pankaj Saxena, MCh, DNB ∗ , Igor E. Konstantinov, MD, PhD, Stuart Downie, MBBS and Mark A.J. Newman, FRACS Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
A
35-year-old man presented to the Emergency Department with increasing chest tightness, palpitations and discomfort of recent onset. There was a significant worsening of symptoms over a week before presentation. On physical examination, the patient had clinical features suggestive of severe aortic regurgitation. The admission ECG showed T-wave inversions in inferior leads, which resolved within 12 h following admission to the hospital. Electrocardiogram (ECG) demonstrated the presence of left ventricular hypertrophy. Transthoracic echocardiography showed a quadricuspid aortic valve with cusp prolapse (Fig. 1) and severe aortic regurgitation (AR). Overall left ventricular function was normal.
Received 16 April 2007; accepted 27 June 2007; available online 4 September 2007 ∗
Corresponding author. Tel.: +61 8 93463333. E-mail address: [email protected] (P. Saxena).
Patient was stabilised medically and underwent aortic valve replacement with 25 mm St Jude valve. Cardiopulmonary bypass was used with systemic hypothermia to 28 ◦ C and myocardial protection using retrograde cold blood cardioplegia with topical hypothermia. Aortic valve at the time of surgery was found to have three large cusps and a small accessory noncoronary cusp (Figs. 2 and 3). Aortic root was normal. Patient made an uncomplicated recovery and was discharged home on day 11. The patient was symptom free and in good health at 1 year of follow up.
Discussion Quadricuspid aortic valve is a rare cause of aortic valve disease with a reported incidence of 0.008–0.033%.1,2 The condition predominantly causes aortic insufficiency. Symptomatic patients with quadricuspid aortic valve and severe AR should be treated with aortic valve replacement. 1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.06.525