Aortic Arch Thrombus and Pulmonary Embolism in a COVID-19 Patient

© 2020 Elsevier Inc. Background: Coronavirus disease 2019 (COVID-19) is associated with endothelial inflammation and a hypercoagulable state resulting in both venous and arterial thromboembolic complications. We present a case of COVID-19-associated aortic thrombus in an otherwise healthy patient. Case Report: A 53-year-old woman with no past medical history presented with a 10-day history of dyspnea, fever, and cough. Her pulse oximetry on room air was 84%. She tested positive for severe acute respiratory syndrome coronavirus 2 infection, and chest radiography revealed moderate patchy bilateral airspace opacities. Serology markers for cytokine storm were significantly elevated, with a serum D-dimer level of 8180 ng/mL (normal \u3c 230 ng/mL). Computed tomography of the chest with i.v. contrast was positive for bilateral ground-glass opacities, scattered filling defects within the bilateral segmental and subsegmental pulmonary arteries, and a large thrombus was present at the aortic arch. The patient was admitted to the intensive care unit and successfully treated with unfractionated heparin, alteplase 50 mg, and argatroban 2 μg/kg/min. Why Should an Emergency Physician Be Aware of This?: Mural aortic thrombus is a rare but serious cause of distal embolism and is typically discovered during an evaluation of cryptogenic arterial embolization to the viscera or extremities. Patients with suspected hypercoagulable states, such as that encountered with COVID-19, should be screened for thromboembolism, and when identified, aggressively anticoagulated

Prognostic Value of Stress Echocardiography in Patients With Low-Intermediate or High Short-Term (10 Years) Versus Low (\u3c39%) or High (\u3e/=39%) Lifetime Predicted Risk of Cardiovascular Disease According to the American College of Cardiology/American Heart Association 2013 Cardiovascular Risk Calculator

This study evaluates the prognostic value of stress echocardiography (Secho) in short-term (10 years) and lifetime atherosclerotic cardiovascular disease risk-defined groups according to the American College of Cardiology/American Heart Association 2013 cardiovascular risk calculator. The ideal risk assessment and management of patients with low-to-intermediate or high short-term versus low (/=39%) lifetime CV risk is unclear. The purpose of this study was to evaluate the prognostic value of Secho in short-term and lifetime CV risk-defined groups. We evaluated 4,566 patients (60 +/- 13 years; 46% men) who underwent Secho (41% treadmill and 59% dobutamine) with low-intermediate short-term (/=39%, n = 661) lifetime CV risk and third group with high short-term risk (\u3e/=20%, n = 3,537). Follow-up (3.2 +/- 1.5 years) for nonfatal myocardial infarction (n = 102) and cardiac death (n = 140) were obtained. By univariate analysis, age (p/=3 new ischemic wall motion abnormalities (WMAs, p/=3 WMA versus(3.3% vs 0.3% per year, p/=3 new ischemic WMAs as the strongest predictor of cardiac events (hazard ratio 3.0, 95% confidence interval 2.3 to 3.9, p/=3 new ischemic segments) can further refine risk assessment in patients with low-intermediate or high short-term versus low or high lifetime cardiovascular risk. Event rate with normal Secho is low

Prevalence and long-term prognosis of patients with complete bundle branch block (right or left bundle branch) with normal left ventricular ejection fraction referred for stress echocardiography

BACKGROUND: The prognostic value of stress echocardiography (SE) in patients with complete bundle branch blocks (BBB) with normal left ventricular ejection fraction (LVEF) has not been well described. We sought to determine the prognostic value of SE in patients with BBB and normal LVEF. METHODS: We analyzed 7214 patients (58 +/- 14 years; 57% female) with a mean follow-up time of 9 +/- 4 years. Dobutamine SE was performed in 51% of patients and exercise SE was performed in 49%. All-cause mortality data were obtained from the Social Security Death Index. RESULTS: There were 222 (3%) patients with right bundle branch block (RBBB) and 50 (0.7%) patients with left bundle branch block (LBBB). Patients with LBBB were 3 times more likely to have an abnormal stress test after adjusting for age, gender, mode of stress test, and coronary artery disease risk factors (OR = 3.3; 95% CI: 1.86-5.92; P \u3c 0.001). The mortality rates were 4.5%/year for patients with LBBB, 2.5%/year for patients with RBBB, and 1.9%/year for patients without BBB (P \u3c 0.001). Among patients with a normal SE, those with LBBB had similar mortality to those without LBBB (HR = 0.9; 95% CI: 0.4-2.2; P = 0.8). Patients with LBBB and abnormal SE had more than 2 times greater risk of all-cause mortality (HR = 2.4; 95% CI: 1.4-4.2; P = 0.002). CONCLUSION: A normal stress echocardiogram in LBBB is associated with benign prognosis while those with LBBB and abnormal SE have the worst outcomes

Feasibility and prognostic value of stress echocardiography in obese, morbidly obese, and super obese patients referred for bariatric surgery

BACKGROUND: Stress echocardiography (SE) is clinically used in the risk stratification and prognosis of patients with coronary artery disease. Due to multiple comorbidities, obese patients have increased risk of adverse cardiovascular events perioperatively in noncardiac surgery. The aim of this study was to investigate the feasibility of SE in morbidly obese patients undergoing bariatric surgery. METHODS: Consecutive patients referred for SE for preoperative evaluation prior to bariatric surgery from January 2002 to July 2011 formed the study cohort. Contrast was used to define the endocardial border in patients with poor acoustic windows. All-cause mortality data were obtained from Social Security Death Index. RESULTS: Six hundred fifty-two patients (47 +/- 10 years, 84% females) with the mean follow-up of 3.0 +/- 2.7 years and mean body mass index (BMI) of 47 +/- 9 kg/m(2) were included in this analysis. Dobutamine SE was performed in 65% of patients compared to exercise SE in 35%. Patients with higher BMI were more likely to undergo dobutamine SE (P \u3c 0.0001). Similarly, incidence of poor acoustic windows and contrast use was higher in those with increased BMI (P \u3c 0.001). Contrast use was higher in patients undergoing dobutamine SE (39%) versus exercise (25%), (P = 0.002). 19 patients (3%) had an abnormal SE and 8 patients (1.2%) died during the follow-up period. CONCLUSION: Stress echocardiography is feasible in the morbidly obese patients. Patients with higher BMI were more likely to undergo dobutamine SE and have higher incidence of poor acoustic windows and contrast use

A Comparative Assessment of Echocardiographic Parameters for Determining Primary Mitral Regurgitation Severity Using Magnetic Resonance Imaging as a Reference Standard.

BACKGROUND: The American Society of Echocardiography (ASE) guidelines suggest the use of several echocardiographic methods to assess mitral regurgitation severity using an integrated approach, without guidance as to the weighting of each parameter. The purpose of this multicenter prospective study was to evaluate the recommended echocardiographic parameters against a reference modality and develop and validate a weighting for each echocardiographic measure of mitral regurgitation severity. METHODS: This study included 112 patients who underwent evaluation with echocardiography and magnetic resonance imaging (MRI). Echocardiographic parameters recommended by the ASE were included and compared with MRI-derived regurgitant volume (MRI-RV). RESULTS: Echocardiographic parameters that correlated best with MRI-RV were proximal isovelocity surface area (PISA) radius (r = 0.65, P \u3c .0001), PISA-derived effective regurgitant orifice area (r = 0.65, P \u3c .0001), left ventricular end-diastolic volume (r = 0.56, P \u3c .0001), and PISA-derived regurgitant volume (r = 0.52, P \u3c .0001). In the linear regression models PISA-derived effective regurgitant orifice area, PISA-derived regurgitant volume, left ventricular end-diastolic volume, and the presence of a flail leaflet independently predicted MRI-RV. CONCLUSION: Echocardiographic parameters of mitral regurgitation as recommended by the ASE had moderate correlations with MRI-RV. The best predictors of MRI-RV were PISA-derived effective regurgitant orifice area, PISA-derived regurgitant volume, left ventricular end-diastolic volume, and the presence of a flail leaflet, suggesting that these parameters should be weighted more heavily than other echocardiographic parameters in the application of the ASE-recommended integrated approach

Combining stress-only myocardial perfusion imaging with coronary calcium scanning as a new paradigm for initial patient work-up: an exploratory analysis

BACKGROUND: We conducted an exploratory analysis to test whether the addition of a CAC scan can increase the applicability of stress-only SPECT-MPI. METHODS: We studied 162 patients referred for rest/stress SPECT-MPI who underwent a CAC scan. Each scan was interpreted by two readers in stepwise fashion: stress-only images; addition of clinical data; and addition of CAC data. At each step, the reader was asked if rest SPECT-MPI was necessary. RESULTS: Stress-only images were interpreted as normal in 62, probably normal in 42, equivocal in 15, probably abnormal in 5, and definitely abnormal in 38 patients. Rest SPECT-MPI imaging was considered necessary, in 0% of normal studies, but in 88% of probably normal studies, and 100% of those with equivocal/abnormal studies. Addition of the clinical data did not materially change this decision. Additional consideration of the CAC scan results did not influence the deemed lack of need for a rest SPECT-MPI with normal SPECT-MPI or the necessity of rest SPECT-MPI with abnormal SPECT-MPI. However, the CAC scan reduced the deemed need for a rest SPECT-MPI in 72% with a probably normal, 47% with an equivocal, and 40% of those with a probably abnormal SPECT-MPI. CONCLUSIONS: Our exploratory analysis indicates that addition of a CAC scan to stress SPECT-MPI tends to diminish experienced readers\u27 deemed need to perform rest SPECT-MPI studies among patients with probably normal or borderline stress-only SPECT-MPI studies. Thus, further study appears warranted to assess the utility of using CAC scanning as a means for increasing the percent of SPECT-MPI studies that can be performed as stress-only studies

Synergistic effect of coronary artery disease risk factors on long-term survival in patients with normal exercise SPECT studies

Background. Normal exercise single-photon emission computed tomography (SPECT) studies are associated with a low event rate (\u3c1.0%/year) during short-term follow-up. The influence of cardiac risk factors on long-term outcomes in such patients has not been well studied. Material and Methods. 2,597 patients (55 ± 12 years, male 41%) without a history of heart disease and a normal exercise SPECT between the years 1995 and 2006 were followed for a mean 6.8 ± 3.1 years for all-cause mortality assessed for using the Social Security Death Index. Baseline clinical risk factors and other clinical information were recorded for each patient and compared to outcomes. Results. The mortality rate was 0.9%/year for our overall study population but varied according to individual baseline risk factors. Three coronary artery disease (CAD) risk factors were significant predictors of all-cause mortality: hypertension, diabetes, and smoking. When all three were absent, long-term all-cause mortality rate averaged 0.2%/year and when all three were present, all-cause mortality averaged 1.8%/year, constituting a 5.7-fold adjusted increase in risk (95% CI 2.7-12.8, P \u3c .0001). Conclusions. During follow-up, annualized mortality rate varies markedly according to the number of CAD risk factors in patients without known heart disease and a normal exercise SPECT stress. Despite overall excellent long-term prognosis of a normal exercise SPECT, the burden of traditional CAD risk factors exert a strong synergistic influence on long-term survival and warrant aggressive treatment in this patient population. Copyright © 2010 American Society of Nuclear Cardiology