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      Right Sided Intracardiac Thrombosis during Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report and Literature Review

      case-report

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          Abstract

          Veno-Arterial Extracorporeal Membrane Oxygenation is a common technology of the modern era used as a bridge in severe refractory cardiac and respiratory failure until definitive management is planned. However, early recognition and management of one of the most challenging complications, intracardiac thrombus, continue to remain a conundrum. The incidence of the clinical scenario is very rare. Therefore, due to the lack of literature, there are no guidelines for risk stratification, prevention, or management of intracardiac thrombus. We describe a case of massive pulmonary embolism, who developed a sudden right sided intra-cardiac thrombosis while being optimally anticoagulated on VA ECMO. We also review the literature to describe the pathophysiology, risk stratification, prevention, and management of this rare entity.

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          Extracorporeal Life Support Organization Registry International Report 2016.

          Ravi Thiagarajan, Steven A Conrad, Matthew L Paden … (2016)
          Data on extracorporeal life support (ECLS) use and survival submitted to the Extracorporeal Life Support Organization's data registry from the inception of the registry in 1989 through July 1, 2016, are summarized in this report. The registry contained information on 78,397 ECLS patients with 58% survival to hospital discharge. Extracorporeal life support use and centers providing ECLS have increased worldwide. Extracorporeal life support use in the support of adults with respiratory and cardiac failure represented the largest growth in the recent time period. Extracorporeal life support indications are expanding, and it is increasingly being used to support cardiopulmonary resuscitation in children and adults. Adverse events during the course of ECLS are common and underscore the need for skilled ECLS management and appropriately trained ECLS personnel and teams.
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            Diabetes mellitus: a hypercoagulable state.

            M E Carr (2015)
            Eighty percent of patients with diabetes mellitus die a thrombotic death. Seventy-five percent of these deaths is due to cardiovascular complications, and the remainder is due to cerebrovascular events and peripheral vascular complications. Vascular endothelium, the primary defense against thrombosis, is abnormal in diabetes. Endothelial abnormalities undoubtedly play a role in the enhanced activation of platelets and clotting factors seen in diabetes. Coagulation activation markers, such as prothrombin activation fragment 1+2 and thrombin-anti-thrombin complexes, are elevated in diabetes. The plasma levels of many clotting factors including fibrinogen, factor VII, factor VIII, factor XI, factor XII, kallikrein, and von Willebrand factor are elevated in diabetes. Conversely, the level of the anticoagulant protein C (PC) is decreased. The fibrinolytic system, the primary means of removing clots, is relatively inhibited in diabetes due to abnormal clot structures that are more resistant to degradation and an increase in plasminogen activator inhibitor type 1 (PAI-1). Increased circulating platelet aggregates, increased platelet aggregation in response to platelet agonists, increased platelet contractile force (PCF), and the presence of higher plasma levels of platelet release products, such as beta-thromboglobulin, platelet factor 4, and thromboxane B(2), demonstrate platelet hyperactivity in diabetes. This constellation of findings supports the clinical observation that diabetes is a hypercoagulable state. This article briefly reviews the published evidence for this conclusion and the putative roles played by hyperglycemia and hyperinsulinemia in its development.
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              Associations of factor VIII and von Willebrand factor with age, race, sex, and risk factors for atherosclerosis. The Atherosclerosis Risk in Communities (ARIC) Study.

              Ni Finch, P Sorlie, G Marcucci … (1993)
              Several coagulation proteins have been implicated as possible risk factors for the development of atherosclerotic diseases, among which are factor VIII and von Willebrand factor. As part of the Atherosclerosis Risk in Communities (ARIC) Study, a prospective study designed to assess risk factors for the development of atherosclerotic diseases, baseline measurements of factor VIII and von Willebrand factor (vWF) were performed to determine their relationship to the development of atherosclerosis. We herein report the associations of factor VIII and vWF with constitutional, lifestyle, and biochemical factors. Factor VIII and vWF were strongly correlated with each other (r = 0.73), and, therefore, had similar associations with risk factors. Mean levels of both factors were higher in women than in men, in blacks than in whites, and increased with age. In univariate analysis, both were positively associated with diabetes, body mass index, waist-to-hip ratio, serum insulin, and plasma triglycerides. Both were negatively associated with alcohol intake, educational level, physical activity (with some exceptions), and HDL-cholesterol. No correlations were observed between factor VIII or vWF and plasma LDL-cholesterol or lipoprotein(a). Although factor VIII was negatively associated with smoking in both sexes, vWF was not associated with smoking status. Most of these associations were confirmed in multivariate analysis. The strongest associations observed were of factor VIII and vWF with race and diabetes. In multivariate analysis, blacks had factor VIII and vWF levels 15 to 18 percentage points higher than whites, and diabetics had factor VIII and vWF levels 11 to 18 percentage points higher than non-diabetics.(ABSTRACT TRUNCATED AT 250 WORDS)
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                Author and article information

                Contributors
                Anusha Ganapati Bhat:
                ORCID: http://orcid.org/0000-0002-6967-0171
                Journal
                Journal ID (nlm-ta): Case Rep Crit Care
                Journal ID (iso-abbrev): Case Rep Crit Care
                Journal ID (publisher-id): CRICC
                Title: Case Reports in Critical Care
                Publisher: Hindawi
                ISSN (Print): 2090-6420
                ISSN (Electronic): 2090-6439
                Publication date Collection: 2019
                Publication date (Electronic): 6 January 2019
                Volume: 2019
                Electronic Location Identifier: 8594681
                Affiliations
                1Department of Internal Medicine, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA
                2Division of Critical Care Medicine, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA
                3Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
                4Division of Cardiology, The University of Texas Medical Branch, Galveston, TX, USA
                Author notes

                Academic Editor: Chiara Lazzeri

                Author information
                http://orcid.org/0000-0002-6967-0171
                http://orcid.org/0000-0001-5376-3288
                Article
                DOI: 10.1155/2019/8594681
                PMC ID: 6339751
                SO-VID: b48ba14b-ac2b-43b1-b969-42a921fa1158
                Copyright © Copyright © 2019 Anusha Ganapati Bhat et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 23 August 2018
                Date accepted : 24 December 2018
                Categories
                Subject: Case Report

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