A 72-year-old man with end-stage renal disease and central venous catheter underwent testing for a right atrial mass. Echocardiography revealed a mobile right atrial mass, and MRI suggested myxoma. Surgery found an infected thrombus attached to the right atrium floor. Histopathology confirmed the difficult differential diagnosis between intracardiac masses. Despite multimodal imaging, pathology was needed for definitive diagnosis of infected thrombus rather than myxoma or vegetation.
Obstruction of the coronary ostium after Transcatheter Aortic Valve Replacement (TAVR) is a rare complication, with an estimated
incidence of approximately 0.66% [1].
The timing of this complication has been established in a bimodal way with either early (1st week) or late (> 60 days) occlusions with
no events in between (subacute) [2].
However, we would like to describe a subacute development of this complication, with an unusual clinical presentation.
Obstruction of the coronary ostium after Transcatheter Aortic Valve Replacement (TAVR) is a rare complication, with an estimated
incidence of approximately 0.66% [1].
The timing of this complication has been established in a bimodal way with either early (1st week) or late (> 60 days) occlusions with
no events in between (subacute) [2].
However, we would like to describe a subacute development of this complication, with an unusual clinical presentation.
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...asclepiuspdfs
Our aim is to present a rare cause of tricuspid valve infective endocarditis (IE) in grown-up age due to cerebrospinal fluid shunt-associated infection. A 32-year-old woman, with a history of hydrocephalus that was treated with ventriculoperitoneal (VP) shunt at the age of 4, was admitted to a hospital due to fever. The VP shunt was replaced several times due to dysfunction and replaced with ventriculoatrial (VA) shunt 3 months before admission. Transesophageal echocardiogram revealed two separate VA catheters in the right atrium, with two floating echo formations, one attached to the tip of one catheter and the other to the anterior leaflet of tricuspid valve. Blood cultures grew methicillin-susceptible Staphylococcus aureus. Computed tomography scan showed bilateral pneumonia. The patient was treated with antibiotics followed by partial extraction of the VA shunt. After 8 weeks, the patient was discharged, without signs of infection. Two months later, she was readmitted due to fever, echocardiographic signs of catheter infection, and septic pulmonary embolization. Complete extraction of VA catheter was done and treatment was continued with antibiotics with complete recovery. Early diagnosis and optimal management that combines both conventional and surgical approaches is crucial for reducing the high embolic risk, risk of complications, and mortality risk.
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...asclepiuspdfs
Hypertrophic obstructive cardiomyopathy is mostly associated with mitral insufficiency rather than mitral stenosis. This association is very rare and no cases have been reported in Africa. Our case was about 22-month-old female child that was referred with a 1-year history of tachypnea and III to IV class of dyspnea. Transthoracic echocardiography showed serious mitral stenosis and a mean gradient of 27 mmHg. The interventricular septum was hypertrophic with a width of 8.5 mm with small aortic annulus, leading subaortic stenosis with a mean gradient of 73 mmHg. There was also a severe pulmonary hypertension at 79 mmHg. It was expected to doing a standard septal myectomy and mitral valve replacement.
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...asclepiuspdfs
Ventricular tachycardia (VT) is a rhythmic emergency due to the poor hemodynamic tolerance, the possibility of transformation into ventricular fibrillation, and the occurrence of sudden death. It is a late complication after thoracic trauma due to ventricular remodeling and scar tissue fibrosis, the main arrhythmogenic substrate. The case we report is that of an 80-year-old patient admitted to our unit for lipothymic discomfort that has been evolving for several months. In this antecedent, we find a violent thoracic traumatism 23 years ago by accident of the public way. On admission, it has a stable hemodynamics; the surface electrocardiogram inscribes a sinus rhythm with diffuse negative T waves and reassuring biology. A few hours after his hospitalization, the discomfort will reappear with unsupported TV. Coronary angiography eliminates an ischemic cause with non-significant atheroma of the bisector. Echocardiography demonstrates a particular aspect of hypertrophy of the left ventricular apex with normal contractile function. Cardiac magnetic resonance imaging shows myocardial fibrosis in this area of hypertrophy and the cardiac computed tomography with three-dimensional reconstruction allows to visualize partial apical inferior disinsertion with an interventricular septum with a thin wall on the right ventricular slope calcified in places with an inlet opening closing in systole. The mechanism of TV in our patient is related to myocardial fibrosis and ventricular remodeling secondary to myocardial contusion 23 years ago. In this context, an implantable automatic defibrillator has been set up with half-yearly monitoring.
Objective To address, in a practical way, the acute treatment of ischemic cerebrovascular accident CVA based on the scientific recommendations latest. Methods A bibliographic search was performed in the PubMed, Scopus, Scielo and Uptodate database from January 2012 to April 2018, using the descriptors stroke , early management , therapeutic , intravenous thrombolysis , combined treatment , mechanical thrombectomy and its combinations. The selection of the articles was made by listing those of greater relevance according to the proposed theme, both in the foreign and Brazilian literature, in a non systematic way. Results Intravenous thrombolysis with recombinant tissue plasminogen activator rtPA within 4.5 hours of onset of symptoms is considered the therapy of choice in eligible patients. According to the new guidelines, mechanical thrombectomy can be performed within 24h and, for prevention of subsequent ischemic events, revascularization between 48h and seven days of the index event in candidate patients is reasonable. Conclusions As an essential cause of death and disability in the world, acute ischemic stroke treatment has advanced rapidly in recent years, improving therapeutic methods and their combinations. In clinical practice, recognizing, stratifying and listing, quickly and effectively, the best therapy for stroke patients is paramount. Renato Serquiz E Pinheiro | Yanny Cinara T Ernesto | Irami Araújo-Neto | Fausto Pierdoná Guzen | Amália Cinthia Meneses Do Rêgo | Irami Araújo-Filho ""Ischemic Brain Vascular Accident: Acute Phase Management"" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-3 , April 2019, URL: https://www.ijtsrd.com/papers/ijtsrd23499.pdf
Paper URL: https://www.ijtsrd.com/biological-science/neurobiology/23499/ischemic-brain-vascular-accident-acute-phase-management/renato-serquiz-e-pinheiro
Valsalva manoeuvre in drug refractory ventricular tachycardiaRamachandra Barik
Ventricular tachycardia (VT) is a cardiac emergency exerting significant morbidity and mortality. Differentiation between VT and supraventricular tachycardia with aberrancy (SVT-A) can be challenging,necessitating awareness of the salient lectrocardiogram (ECG)criteria1 and at times, proven refractoriness to adenosine. Despite well-established guidelines and evidence-based anti-arrhythmic medications for VT management, the role of Valsalva manoeuvre (VM) as
an effective treatment for VT remains controversial.2,3 In this case report, we describe a patient who presented with multiple
drug-refractory VTs, one of which repeatedly terminated by VM.
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...asclepiuspdfs
Our aim is to present a rare cause of tricuspid valve infective endocarditis (IE) in grown-up age due to cerebrospinal fluid shunt-associated infection. A 32-year-old woman, with a history of hydrocephalus that was treated with ventriculoperitoneal (VP) shunt at the age of 4, was admitted to a hospital due to fever. The VP shunt was replaced several times due to dysfunction and replaced with ventriculoatrial (VA) shunt 3 months before admission. Transesophageal echocardiogram revealed two separate VA catheters in the right atrium, with two floating echo formations, one attached to the tip of one catheter and the other to the anterior leaflet of tricuspid valve. Blood cultures grew methicillin-susceptible Staphylococcus aureus. Computed tomography scan showed bilateral pneumonia. The patient was treated with antibiotics followed by partial extraction of the VA shunt. After 8 weeks, the patient was discharged, without signs of infection. Two months later, she was readmitted due to fever, echocardiographic signs of catheter infection, and septic pulmonary embolization. Complete extraction of VA catheter was done and treatment was continued with antibiotics with complete recovery. Early diagnosis and optimal management that combines both conventional and surgical approaches is crucial for reducing the high embolic risk, risk of complications, and mortality risk.
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...asclepiuspdfs
Hypertrophic obstructive cardiomyopathy is mostly associated with mitral insufficiency rather than mitral stenosis. This association is very rare and no cases have been reported in Africa. Our case was about 22-month-old female child that was referred with a 1-year history of tachypnea and III to IV class of dyspnea. Transthoracic echocardiography showed serious mitral stenosis and a mean gradient of 27 mmHg. The interventricular septum was hypertrophic with a width of 8.5 mm with small aortic annulus, leading subaortic stenosis with a mean gradient of 73 mmHg. There was also a severe pulmonary hypertension at 79 mmHg. It was expected to doing a standard septal myectomy and mitral valve replacement.
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...asclepiuspdfs
Ventricular tachycardia (VT) is a rhythmic emergency due to the poor hemodynamic tolerance, the possibility of transformation into ventricular fibrillation, and the occurrence of sudden death. It is a late complication after thoracic trauma due to ventricular remodeling and scar tissue fibrosis, the main arrhythmogenic substrate. The case we report is that of an 80-year-old patient admitted to our unit for lipothymic discomfort that has been evolving for several months. In this antecedent, we find a violent thoracic traumatism 23 years ago by accident of the public way. On admission, it has a stable hemodynamics; the surface electrocardiogram inscribes a sinus rhythm with diffuse negative T waves and reassuring biology. A few hours after his hospitalization, the discomfort will reappear with unsupported TV. Coronary angiography eliminates an ischemic cause with non-significant atheroma of the bisector. Echocardiography demonstrates a particular aspect of hypertrophy of the left ventricular apex with normal contractile function. Cardiac magnetic resonance imaging shows myocardial fibrosis in this area of hypertrophy and the cardiac computed tomography with three-dimensional reconstruction allows to visualize partial apical inferior disinsertion with an interventricular septum with a thin wall on the right ventricular slope calcified in places with an inlet opening closing in systole. The mechanism of TV in our patient is related to myocardial fibrosis and ventricular remodeling secondary to myocardial contusion 23 years ago. In this context, an implantable automatic defibrillator has been set up with half-yearly monitoring.
Objective To address, in a practical way, the acute treatment of ischemic cerebrovascular accident CVA based on the scientific recommendations latest. Methods A bibliographic search was performed in the PubMed, Scopus, Scielo and Uptodate database from January 2012 to April 2018, using the descriptors stroke , early management , therapeutic , intravenous thrombolysis , combined treatment , mechanical thrombectomy and its combinations. The selection of the articles was made by listing those of greater relevance according to the proposed theme, both in the foreign and Brazilian literature, in a non systematic way. Results Intravenous thrombolysis with recombinant tissue plasminogen activator rtPA within 4.5 hours of onset of symptoms is considered the therapy of choice in eligible patients. According to the new guidelines, mechanical thrombectomy can be performed within 24h and, for prevention of subsequent ischemic events, revascularization between 48h and seven days of the index event in candidate patients is reasonable. Conclusions As an essential cause of death and disability in the world, acute ischemic stroke treatment has advanced rapidly in recent years, improving therapeutic methods and their combinations. In clinical practice, recognizing, stratifying and listing, quickly and effectively, the best therapy for stroke patients is paramount. Renato Serquiz E Pinheiro | Yanny Cinara T Ernesto | Irami Araújo-Neto | Fausto Pierdoná Guzen | Amália Cinthia Meneses Do Rêgo | Irami Araújo-Filho ""Ischemic Brain Vascular Accident: Acute Phase Management"" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-3 , April 2019, URL: https://www.ijtsrd.com/papers/ijtsrd23499.pdf
Paper URL: https://www.ijtsrd.com/biological-science/neurobiology/23499/ischemic-brain-vascular-accident-acute-phase-management/renato-serquiz-e-pinheiro
Valsalva manoeuvre in drug refractory ventricular tachycardiaRamachandra Barik
Ventricular tachycardia (VT) is a cardiac emergency exerting significant morbidity and mortality. Differentiation between VT and supraventricular tachycardia with aberrancy (SVT-A) can be challenging,necessitating awareness of the salient lectrocardiogram (ECG)criteria1 and at times, proven refractoriness to adenosine. Despite well-established guidelines and evidence-based anti-arrhythmic medications for VT management, the role of Valsalva manoeuvre (VM) as
an effective treatment for VT remains controversial.2,3 In this case report, we describe a patient who presented with multiple
drug-refractory VTs, one of which repeatedly terminated by VM.
Background: Myocarditis is a relatively common inflammatory disease that affects the myocardium. Infectious disease accounts for most of the cases either because of a direct viral infection or post-viral immune-mediated reaction. Cardiovascular magnetic resonance (CMR) has become an established non-invasive diagnosis tool for acute myocarditis. A recent large single centre study with patients with biopsy-proven viral myocarditis undergoing CMR scans found a high rate of mortality. The aim of this study was to assess the rate of clinical events in our population of patients with diagnosed myocarditis by CMR scan.
Methods: Patients who consulted to the emergency department with diagnosis of myocarditis by CMR were retrospectively included in the study from January 2008 to May 2012. A CMR protocol was used in all patients, and were followed up to assess the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or implantable cardiac defibrillator (ICD). A descriptive statistical analysis was performed.
Results: Thirty-two patients with myocarditis were included in the study. The mean age was 42.6±21.2 years and 81.2% were male. In a mean follow up of 30.4±17.8 months, the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or ICD was 15.6% (n=5). Two patients had heart failure (one of them underwent heart transplant), one patient needed ICD because of ventricular tachycardia and two other patients were re-hospitalized, for recurrent chest pain and for recurrent myocarditis respectively.
Conclusions: In our series of acute myocarditis diagnosed by CMR we found a low rate of cardiovascular events without mortality. These findings might oppose data from recently published myocarditis trials.
IMAGES OF A COMPLEX CASE OF MULTIPLE ANEURYSMAL DISEASE IN A 58 YEAR OLD MAN
IMMAGINI DI UN CASO COMPLESSO DI MALATTIA POLINEURISMATICA
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
Objective: To investigate the effects of nicorandil and tirofiban on no-reflow and postoperative outcome in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention.
Study Design: A total of 438 patients with ACS diagnosed by the second Hospital of Shanxi Medical University from January 2019 to December 2020 were divided into two groups: nicorandil group (n=223) and tirofiban group (n=215). The nicorandil group was injected with 2 mg nicorandil 2 mm before coronary occlusion before balloon dilation, and the tirofiban group received 10 μg/kg intravenous injection during operation. Measurement of thrombolysis grade (thrombolysis in myocardial infarction [TIMI]), corrected TIMI frame count, and major adverse vascular events were recorded 30 days after operation in patients with ACS.
Results: Both nicorandil and tirofiban could improve the TIMI grade, and TIMI grade 3 blood flow was obtained in 190 cases (85.2%) and 175 cases (81.4%), respectively. There was no significant difference in the incidence of major adverse cardiac events (14.3% vs. 13.5%, score 0.13).
Conclusion: Intracoronary use of nicorandil in patients with ACS can improve coronary perfusion, but the improvement of prognosis needs further study.
Keywords: coronary perfusion, myocardial infarction, nicorandil, no-reflow phenomenon, percutaneous coronary intervention, repercussion
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Veterinary Diagnostics Market PPT 2024: Size, Growth, Demand and Forecast til...IMARC Group
The global veterinary diagnostics market size reached US$ 6.6 Billion in 2023. Looking forward, IMARC Group expects the market to reach US$ 12.6 Billion by 2032, exhibiting a growth rate (CAGR) of 7.3% during 2024-2032.
More Info:- https://www.imarcgroup.com/veterinary-diagnostics-market
LGBTQ+ Adults: Unique Opportunities and Inclusive Approaches to CareVITASAuthor
This webinar helps clinicians understand the unique healthcare needs of the LGBTQ+ community, primarily in relation to end-of-life care. Topics include social and cultural background and challenges, healthcare disparities, advanced care planning, and strategies for reaching the community and improving quality of care.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Cold Sores: Causes, Treatments, and Prevention Strategies | The Lifesciences ...The Lifesciences Magazine
Cold Sores, medically known as herpes labialis, are caused by the herpes simplex virus (HSV). HSV-1 is primarily responsible for cold sores, although HSV-2 can also contribute in some cases.
International Cancer Survivors Day is celebrated during June, placing the spotlight not only on cancer survivors, but also their caregivers.
CANSA has compiled a list of tips and guidelines of support:
https://cansa.org.za/who-cares-for-cancer-patients-caregivers/
Trauma Outpatient Center is a comprehensive facility dedicated to addressing mental health challenges and providing medication-assisted treatment. We offer a diverse range of services aimed at assisting individuals in overcoming addiction, mental health disorders, and related obstacles. Our team consists of seasoned professionals who are both experienced and compassionate, committed to delivering the highest standard of care to our clients. By utilizing evidence-based treatment methods, we strive to help our clients achieve their goals and lead healthier, more fulfilling lives.
Our mission is to provide a safe and supportive environment where our clients can receive the highest quality of care. We are dedicated to assisting our clients in reaching their objectives and improving their overall well-being. We prioritize our clients' needs and individualize treatment plans to ensure they receive tailored care. Our approach is rooted in evidence-based practices proven effective in treating addiction and mental health disorders.
Rate Controlled Drug Delivery Systems, Activation Modulated Drug Delivery Systems, Mechanically activated, pH activated, Enzyme activated, Osmotic activated Drug Delivery Systems, Feedback regulated Drug Delivery Systems systems are discussed here.
Under Pressure : Kenneth Kruk's StrategyKenneth Kruk
Kenneth Kruk's story of transforming challenges into opportunities by leading successful medical record transitions and bridging scientific knowledge gaps during COVID-19.
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...rightmanforbloodline
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
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Tips for Pet Care in winters How to take care of pets.
misdiagnosis for right atrial mass
1. .............................................
Misdiagnosis for right atrial mass: a case report
Martha Alehli Rangel-Herna´ndez1,2
, Alberto Aranda-Fraustro3
,
Gabriela Melendez-Ramirez4
, and Nilda Espı´nola-Zavaleta2
*
1
Research Internship, Institute of Biomedical Sciences, Autonomous University of Ciudad Juarez, 32310, Chihuahua, Mexico; 2
Nuclear Medicine Department, National Institute of
Cardiology Ignacio Chavez, Tlalpan, 14080, Mexico City, Mexico; 3
Pathology Department, National Institute of Cardiology Ignacio Chavez, Tlalpan, 14080, Mexico City, Mexico;
and 4
Magnetic Resonance Imaging Department, National Institute of Cardiology Ignacio Chavez, Tlalpan, 14080, Mexico City, Mexico
Received 29 September 2017; accepted 2 January 2018; online publish-ahead-of-print 24 January 2018
Introduction Patients with chronic kidney disease undergoing haemodialysis (HD) therapy have high morbidity and mortality, the
main causes are cardiovascular events followed by infectious disease. Infectious problems originate from the vascu-
lar access, especially when such access is through a central venous catheter.
...................................................................................................................................................................................................
Case
presentation
We described a 72-year-old man with end-stage renal disease, requiring HD, with fever and purulent discharge at
the catheter insertion site. Transthoracic echocardiography revealed a 39 Â 27 mm mobile mass in the right atrium.
Magnetic resonance imaging showed a 53 Â 45 Â 36 mm mass suggesting myxoma. The patient underwent surgery
and a mass of approximately 5 Â 6 cm was found attached to the floor of the right atrium, next to the inferior vena
cava outlet, without affecting the tricuspid valve or the interatrial septum. Histopathology reported infected throm-
bus. This case confirms that sometimes it is difficult to perform a differential diagnosis between intracardiac masses.
The patient showed full clinical recovery during this period and was discharged. Currently, he is in good clinical
condition and attends follow-up clinic of nephrology, regularly.
...................................................................................................................................................................................................
Discussion In HD patients, a high index of suspicion is very important in the early recognition and management of infective
endocarditis. Imaging studies are very useful for the diagnosis of intracardiac masses, but sometimes it is difficult to
differentiate one mass from another. In our case, despite the multimodal approach, the histopathological study was
the one that gave us the definitive diagnosis.
Keywords Intracardiac mass • Echocardiography • Infective endocarditis • Chronic kidney
disease • Haemodialysis • Case report
Introduction
Patients with chronic kidney disease (CKD) undergoing haemodialysis
(HD) therapy have high morbidity and mortality, the main causes are
cardiovascular events followed by infectious disease. Infectious prob-
lems originate from the vascular access, especially when such access is
through a central venous catheter (CVC). The increase in CVC use has
led to an increase in the number of cases of infective endocarditis (IE)1
(up to 9% incidence), being one of the most severe complications and
with a worse prognosis, with a mortality of 25–45% during hospitaliza-
tion and of 46–75% per year.2
The CVC, besides being a septic focus, is
considered a risk factor that predisposes to the formation of thrombi.3
In addition to this, it has been shown that patients with CKD have an
Learning points
• Patients with chronic kidney disease (CKD) have risk factors
that predispose to thrombus and vegetation.
• The central venous catheter, besides being a septic focus, is
considered a risk factor that predisposes to the formation of
thrombi.
• Patients with CKD have an increased risk of thrombosis and/
or atherothrombotic events, such as atrial fibrillation.
• Imaging studies are very useful for performing a differential
diagnosis between intracardiac masses.
* Corresponding author. Tel: þ5255 55732911; ext 21001, Fax: þ52 55 56063931, Email: niesza2001@hotmail.com. This case report was reviewed by Francesco Lo Iudice and
Tor Biering-Sørensen and Hajnalka Va´go´.
VC The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Cardiology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
journals.permissions@oup.com
European Heart Journal - Case Reports (2018) 2, 1–6 CASE REPORT
doi:10.1093/ehjcr/yty004 Cardiac Imaging
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2. ...........................................................................................................................
increased risk of thrombosis,4,5
and/or atherothrombotic events, such
as atrial fibrillation.6
Imaging studies are very useful for the diagnosis of intracardiac
masses (tumours, thrombi, or vegetations). However, sometimes it is
difficult to differentiate one mass from another, especially in patients
with comorbidities and/or high risk factors, such as patients with CKD,
which as mentioned above, have risk factors that predispose to both
thrombus and vegetations.
Timeline
Case report
We present a 72-year-old man with history of systemic arterial
hypertension, diabetes mellitus Type 2 and end-stage renal disease,
secondary to diabetic nephropathy requiring renal substitution ther-
apy since 2013, initially under peritoneal dialysis modality, migrating
to HD with jugular Mahurkar catheter in 2015.
On the 25 March 2016, he started with intermittent high fever and
purulent discharge at the Mahurkar catheter insertion site; he was
treated with vancomycin without response, for which he was hospital-
ized in the Medical Centre ISSEMYM Arturo Montiel, Toluca City.
During his stay, the right jugular catheter was removed and a left jugu-
lar catheter and right femoral vascular access for dialysis were placed.
Transthoracic echocardiogram (TTE) reported a mobile mass in the
right atrium, suggestive of vegetation that generated severe obstruc-
tion of the tricuspid valve. Treatment with meropenem and gentamicin
were given for IE as soon the causative agent of infection was identified
(Staphylococcus epidermidis) based on MC&S from catheter tip.
On the 29 April 2016, the patient was referred to the National
Institute of Cardiology Ignacio Chavez to continue therapeutic and
surgical management. At admission he was haemodynamically stable
(heart rate (HR) 89/min, blood pressure (BP) 140/90mmHg, respir-
tory frequency (RF) 18r.p.m., and temperature 36.6
C). On ausculta-
tion no murmurs were heard and the electrocardiogram (ECG)
reported atrial fibrillation with a mean heart rate of 89 b.p.m., without
ST segment or T-wave alterations and right bundle brunch block
(Figure 1). The inflammatory markers at his admission were: C-reactive
protein, 161mg/L (normal ranges 0.00–6.80); erythrocyte sedimenta-
tion rate, 86mm/h (normal ranges 1.00–8.00); and white blood cell,
10Â 103
/mL (normal ranges 4.00–10.5).
Transthoracic echocardiogram revealed a mobile mass of
39Â 27mm in the right atrium, which was corroborated on the
transoesophageal echocardiography with dimensions of 40Â 39 mm;
the mass was attached at the junction of the inferior vena cava outlet
and the right atrium, (Figure 2). Cardiac magnetic resonance imaging
(CMRI) using the sequences T1, T2, T2-short tau inversion recovery
(STIR), early gadolinium, and late gadolinium, showed a
53Â 45Â 36mm mobile oval mass in the right atrium, attached to
the floor of the atrium, adjacent to the inferior vena cava outlet, with
suggestive characteristics of myxoma (Figure 3).
1987 Diabetes mellitus Type 2
1989 Systemic arterial hypertension
2012 Chronic renal disease secondary to diabetic
nephropathy
2013 End-stage renal disease secondary to diabetic
nephropathy
Renal substitution therapy in 2013 (starting with
peritoneal dialysis modality)
2014 Migrates from peritoneal dialysis to haemodialysis
modality (with right jugular Mahurkar catheter)
25 March 2016 Intermittent high fever
4 April 2016 Purulent discharge at the Mahurkar jugular catheter
insertion site
7 April 2016 Vancomycin intravenously was administered and
out-patient management is recommended
12 April 2016 Patient was hospitalized and continued with antibiotic
Right jugular Mahurkar catheter was removed
Left jugular Mahurkar catheter and right femoral
access for dialysis were placed
14 April 2016 Transthoracic echocardiography reported a mobile
mass in the right atrium, suggestive of vegetation
Staphylococcus epidermidis was identified so merope-
nem and gentamicin were given for infective
endocarditis treatment
2 May 2016 The patient was referred to National Institute of
Cardiology Ignacio Chavez in Mexico City
6 May 2016 Transthoracic echocardiogram
11 May 2016 Transoesophageal echocardiogram
Both reported a mobile mass in the right atrium
11 May 2016 Cardiac magnetic resonance imaging: mobile oval
mass attached to the floor of the right atrium
suggestive of myxoma
16 May 2016 The case was discussed in a medical and surgical session,
where patient was accepted for tumour surgical
resection
18 May 2016 Surgical resection of the mass and treatment
with antibiotic
21 May 2016 Subcutaneous administration of Enoxaparin
40 mg/24 h
30 May 2016 Histopathology reported an infected thrombus
with Gram-positive bacterial colonies sensitive
to cephalothin-prescribed for 2 weeks
Continued
31 May 2016 Repeat transthoracic echocardiogram without evi-
dence of residual right atrial mass and without
pericardial effusion
3 June 2016 Left brachiocephalic arteriovenous fistula
4 June 2016 Started with acenocoumarol orally
7 June 2016 Enoxaparin was suspended
13 June 2016 Last session of haemodialysis with ultrafiltration of
3000 mL
14 June 2016 Full recovery and discharge with indication of regu-
larly follow-up in the clinic of nephrology in his
city and cephalexin 500 mg every 8 h orally, for
4 weeks
29 August 2017 Last follow-up. Patient in good clinical condition
................................................
2 M.A. Rangel-Herna´ndez et al.
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3. Figure 1 Atrial fibrillation with a mean heart rate of 89 b.p.m. Right bundle brunch block.
Figure 2 Transoesophageal bidimensional echocardiography (A-0
, B-0
, and D-95
) showing a mass in the right atrium (yellow arrows) with irreg-
ular contour and heterogeneous echogenicity. The mass is avascular with colour flow (C-45
). LA, left atrium; LV, left ventricle; RV, right ventricle;
Ao, aorta; SVC, superior vena cava.
Right atrial mass 3
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4. ....................................................................................
The patient underwent surgery to remove the mass of approxi-
mately 5Â 6 cm attached to the floor of the right atrium, next to the
inferior vena cava outlet, without affecting the tricuspid valve, or the
interatrial septum. The histopathological report gave the diagnosis of
infected thrombus with Gram-positive bacterial colonies (Figure 4)
sensitive to cefalotin, antibiotic was given for 2 weeks and also enoxa-
parin 40mg/24h our, and before discharge acenocoumarol was
added guided by International normalised ratio (INR) in order to sus-
pend enoxaparin. The repeat TTE performed on 31 May 2016,
showed no evidence of residual mass in the right atrium. The patient
showed full clinical recovery during this period and was discharged
on 14 June 2016. No adverse and unanticipated events were
detected in the regular follow-up at the nephrology clinic and cepha-
lexin 500 mg was continued every 8 hrs orally, for 4 weeks. The most
recent follow-up was on 29 August 2017 and the patient is in good
clinical condition.
Discussion
In our case, because of the history of IE and purulent discharge at the
catheter insertion site, it was initially suspected that the mass was
vegetation, however, on heart auscultation, no murmurs were heard
and the TTE reported a structurally normal tricuspid valve, without
lesions or presence of vegetations. Even though, on Figure 2D the
mass looks pedunculated and may suggested a myxoma, in most
cases, myxomas usually arise from fossa ovalis of the interatrial sep-
tum and protrude into the atrium; also our patient was in atrial
fibrillation and had dilatation of both atrial cavities, findings that give
us a strong suspicion of thrombus.7
Imaging studies are very useful for the diagnosis of intracardiac
masses (myxoma, thrombus, and infected thrombus), but sometimes
it is difficult to differentiate one mass from another.8–14
Cardiac magnetic resonance imaging showed a 53Â 45Â 36 mm
mobile oval mass in the right atrium, attached to its floor, adjacent to
the inferior vena cava outlet, with suggestive features of myxoma.
The superior tissue characterization capability of CMRI is able to
determine the nature of some tumours pre-operatively and performs
well in differentiating myxomas from thrombus. The different com-
position of myxoid tissue, fibrous tissue, blood, and haemorrhagic
breakdown products contained within myxomas result in significant
variability of signal characteristics exhibited by these lesions on CMRI
(Table 1).13–15
Thrombus represents the principle differential diagnosis for
myxomas. The age of the thrombus determines its CMRI signal charac-
teristics. Acute thrombus, predominantly containing oxyhaemoglobin
return intermediate signal on T1- and T2-weighted sequences. As the
thrombus becomes more organized, the water content diminishes and
the methaemoglobin rich cellular fragments are replaced by fibrous tis-
sue. Chronic thrombi return low signal on T1- and T2-weighted
sequences. Contrast enhanced sequences: first pass perfusion and late
gadolinium enhancement is important in distinguishing myxomas from
thrombus. Thrombi are avascular masses and therefore, do not typi-
cally enhance on first pass perfusion. Early gadolinium at inversion
times of 550–650 typically shows the thrombus to appear dark.9,16
Figure 3 Magnetic resonance imaging in four chambers (A–D) and two chambers of the right cavities (E–H). The magnetic resonance imaging
showed an oval mobile mass adhered to the floor of the right atrium, adjacent to the inferior vena cava, that measures 53Â 45Â 36mm. In all the
magnetic resonance imaging sequences the mass showed heterogeneous signal intensity. It was predominantly isointense in T1 (A, E) and T1 fat-sat
(B, F) with hypointense centre. In T2-weighted (C, G), it was predominantly isointense, with some hyperintense zones and with hypointense centre. In
T2* hypointense focus was also identified in the centre of the lesion. Fat content was not identified.
4 M.A. Rangel-Herna´ndez et al.
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5. Figure 4 (A and B) Laminated thrombus with fibrin (HE 10Â). (C) Some areas of thrombus with purple bacterial colonies (arrows) (HE 10Â).
(D) Necrotic areas (arrows) with leucocyte infiltrate (HE 40Â). (E) Gram-positive cocci that form grapelike clusters (Gram HE 100Â).
(F) Fragmenting thrombus with a total weight of approximately 20g. They are blackish brown with whitish areas and friable consistency. HE: hema-
toxylin eosin staining.
....................................................................................................................................................................................................................
Table 1 Cardiac magnetic resonance imaging sequences for differential diagnosis of myxoma, thrombus, and infected
thrombus
MRI weighted
sequences
Myxoma Thrombus Infected thrombus
T1 Isointensity signal Low to intermediate signal Low to high signal
Acute thrombus-Intermediate signal
Chronic thrombus-Low signal
T2 High signal Low to intermediate signal Low to high signal
Acute thrombus-intermediate signal
Chronic thrombus-low signal
T2* Isointensity signal Hypointensity signal (if acute) Isointensity signal
T2-STIR High signal intensity indicates a high water
content caused by active inflammation
and/or oedema
Low (if acute-high) Low signal
T2 fat-Sat High signal Isointensity signal Isointensity signal
Early perfusion Lower vascularity Avascularity Avascularity
Early gadolinium Minimal early contrast enhancement of the mass No uptake No uptake
Late gadolinium No late enhancement (important discriminator
from a thrombus)
No uptake No uptake
MRI: magnetic resonance imaging; STIR: short tau inversion recovery.
Right atrial mass 5
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6. ................................................................................................Infected thrombus returns isointensity signal on T1, T2, and T2*. For
this reason, we wanted to summarize some of the CMRI characteris-
tics that can help us reach the aetiological diagnosis (Table 1).10–12
In our case, the behaviour of the CMRI sequences were similar
for both myxoma and thrombus and no contrast media was
administered, that could have helped us in establishing the differential diag-
nosis between myxomas and thrombus, because our patient has CKD
and this would have represented a risk of nefrogenic systemic fibrosis.
Conclusion
In HD patients a high index of suspicion is very important in the early
recognition and management of IE. Imaging studies are very useful for
the diagnosis of intracardiac masses, but sometimes it is difficult to dif-
ferentiate one mass from another. In our case despite the multimodal
approach, the histopathological study was the one that gave us the
definitive diagnosis.
Funding
The National Institute of Cardiology Ignacio Chavez helped us with
the payment of publishing rights.
Consent: The author/s confirm that written consent for submission
and publication of this case report including image(s) and associated
text has been obtained from the patient in line with COPE guidance.
Conflict of interest: none declared.
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