Persistent pulmonary vein thrombosis
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Persistent pulmonary vein thrombosis Marco Rolando1 · Giacomo Ingallina1 · Stefano Stella1 · Renata Mellone2 · Francesco Ancona1 · Cristina Capogrosso1 · Francesco Melillo1 · Eustachio Agricola1,3 Received: 26 October 2020 / Accepted: 30 October 2020 © Springer Nature B.V. 2020
A 75-year-old female was referred to our emergency department for the acute onset of diplopia and bilateral scotoma. The patient had a history of dedifferentiated acinic cell carcinoma of parotid gland managed with surgery, radiation therapy and subsequent chemotherapy for metastases. She was already treated with Edoxaban 60 qd for four months since the incidental finding of right pulmonary vein thrombus (PVT) at a computed tomography (CT) scan of the chest. On examination, the patient appeared comfortable. She was on sinus rhythm and her blood tests were within normal limits except for a slight worsening of renal function (Creatinine 1.2 mg/dl, stage III Chronic Kidney Disease) and the level of plasma Edoxaban dosage (188 ng/ml (RV 19.0–62.0 ng/ml)) confirming the therapeutic range of the drug. Brain CT and Magnetic Resonance Imaging Scan revealed multiple posterior acute cerebral ischemic lesions (Fig. 1). For the risk of contrast-induced nephropathy instead of CT scan a transesophageal echocardiography (TEE) to reassess the PVT was performed. TEE showed the persistence of the thrombus protruding in LA from the right superior pulmonary vein (RSPV). It was an oscillating hypoechoic mass of 50 × 12 mm (Fig. 1) with “papillary-like” shape at real-time three-dimensional echocardiography (RT3DE) (Fig. 1). In order to directly compare the two exams
a reconstruction of the TEE views (Fig. 1) from the dataset of the CT scan performed four months before was made through a specific software. After confirming the PVT anticoagulant therapy was changed from Edoxaban 60 mg qd to Dabigatran 150 mg bid, which demonstrated the greatest absolute reduction in risk of stroke compared to warfarin in atrial fibrillation. After 2 weeks, the patient was discharged with complete neurological recovery. PVT is a rare condition in which most patients are asymptomatic. There are several risk factors described in literature with most cases due to neoplastic disease [1]. Multimodality imaging is helpful to evaluate intracardiac masses: CT scan allows full visualization of the heart and mediastinum, that is crucial to identify origin, extension and relationship of the masses with nearby structures [1, 2] and RT-3DE assessment is useful to analyze the consistency, mobility and hemodynamic effects of masses [1]. To the best of our knowledge, this is the first case in which the evolution of a PVT was studied with multimodality imaging approach: the reconstruction of TEE views directly from CT dataset allowed a direct comparison between the two techniques demonstrating that the thrombus was not reduced after four months of anticoagulation.
Electronic Supplementary Material The online version of this article (https://doi.org/10.1007/s10554-0
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