Images in Clinical Rheumatology
Antiphospholipid syndrome: A recurrent cardiac thromboembolic insult in spite of optimal anticoagulation
Síndrome antifosfolípido: lesión tromboembólica cardiaca recurrente a pesar de anticoagulación óptima
André Viveiros Monteiro
, Luísa Moura Branco, Lídia de Sousa, Rui Cruz Ferreira
Corresponding author
Cardiology Department, Hospital of Santa Marta, Lisbon, Portugal
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"Monteiro" "email" => array:1 [ 0 => "andreviveirosmonteiro@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Luísa Moura" "apellidos" => "Branco" ] 2 => array:2 [ "nombre" => "Lídia" "apellidos" => "de Sousa" ] 3 => array:2 [ "nombre" => "Rui Cruz" "apellidos" => "Ferreira" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, Hospital of Santa Marta, Lisbon, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome antifosfolípido: lesión tromboembólica cardiaca recurrente a pesar de anticoagulación óptima" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Image 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1273 "Ancho" => 1650 "Tamanyo" => 133226 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Apical 5-chamber echocardiogram view showing a thrombus in the right atrium.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Antiphospholipid syndrome (APS) is an autoimmune disease, with antiphospholipid antibodies associated with hypercoagulability, vascular thrombosis, and fetal loss.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Cardiac involvement occurs frequently, and is deeply related to hypercoagulability in spite of recommended anticoagulant therapy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In this report, we describe the images of a Caucasian 19-year-old male, with a previous history, 4 years earlier, of an acute in situ right chamber thromboembolic episode submitted to a surgical intracardiac thrombectomy. At this time APS was diagnosed with increased levels of lupus anticoagulant and IgM anti-beta(2)-glycoprotein I. All other autoantibodies were negative. He was readmitted in April 2012 with an initial suspicion of endocarditis. Intracardiac and inferior vena cava thrombi as well as acute and chronic pulmonary thromboembolism were detected in spite of adequate anticoagulation. After full dose anticoagulation he improved well and was discharged. In September 2012 he was readmitted after 2 weeks of fever, dyspnea and left thoracic pain again with pulmonary thromboembolism. Transthoracic echocardiogram (TTE) revealed an image suggestive of a thrombus at the upper part of the atrial septum in the right atrium (25<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm), <a class="elsevierStyleCrossRef" href="#fig0005">Image 1</a>, and in the inferior vena cava (18<span class="elsevierStyleHsp" style=""></span>mm) near the roof of the right atrium, <a class="elsevierStyleCrossRef" href="#fig0010">Image 2</a>. Also in the infundibulum of the right ventricle and in the right ventricular outflow tract several freely moving masses were visualized, indicative of thrombus near the lateral wall, <a class="elsevierStyleCrossRef" href="#fig0015">Image 3</a>. A long course of antibiotic was done and all microbiological tests proved negative. Hydroxychloroquine and colchicine were added to an intensive antithrombotic regimen of acenocumarol, enoxaparin and acetylsalicylic acid with a significant reduction of the right atrium and inferior vena cava thrombi and a complete disappearance of the right ventricular masses. The patient improved clinically and no further relapses were observed during follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical responsibilities</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of people and animals</span><p id="par0010" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data confidentiality</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Image 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1273 "Ancho" => 1650 "Tamanyo" => 133226 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Apical 5-chamber echocardiogram view showing a thrombus in the right atrium.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Image 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1391 "Ancho" => 1650 "Tamanyo" => 137195 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Subcostal echocardiogram view showing a thrombus in the inferior vena cava.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Image 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1284 "Ancho" => 1663 "Tamanyo" => 161242 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Apical 5-chamber echocardiogram view showing thrombi in the right ventricle.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The cardiac manifestations of antiphospholipid syndrome and their echocardiographic recognition" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.J. Silbiger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Echocardiogr" "fecha" => "2009" "volumen" => "22" "paginaInicial" => "1100" "paginaFinal" => "1108" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reversible cardiac valvular disease in catastrophic antiphospholipid syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.C. Teunisse" 1 => "A.J. Kalsbeek" 2 => "S.T. de Vries" 3 => "S.J. Huisman" 4 => "J.E. Boers" 5 => "A. Breeman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Neth J Med" "fecha" => "2010" "volumen" => "68" "paginaInicial" => "215" "paginaFinal" => "220" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20508270" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of antiphospholipid syndrome in cardiovascular disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.R. Long" 1 => "F. Leya" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hoc.2007.10.002" "Revista" => array:6 [ "tituloSerie" => "Hematol Oncol Clin North Am" "fecha" => "2008" "volumen" => "22" "paginaInicial" => "79" "paginaFinal" => "94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18207067" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001100000003/v2_201505050301/S2173574315000404/v2_201505050301/en/main.assets" "Apartado" => array:4 [ "identificador" => "5795" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in Clinical Rheumatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001100000003/v2_201505050301/S2173574315000404/v2_201505050301/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574315000404?idApp=UINPBA00004M" ]
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| 2017 April | 14 | 7 | 21 |
| 2017 March | 9 | 15 | 24 |
| 2017 February | 11 | 5 | 16 |
| 2017 January | 17 | 3 | 20 |
| 2016 December | 32 | 15 | 47 |
| 2016 November | 30 | 8 | 38 |
| 2016 October | 34 | 3 | 37 |
| 2016 September | 31 | 1 | 32 |
| 2016 August | 33 | 7 | 40 |
| 2016 July | 9 | 1 | 10 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 1 | 10 | 11 |
| 2015 October | 1 | 18 | 19 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 2 | 21 | 23 |
| 2015 July | 15 | 10 | 25 |
| 2015 June | 32 | 12 | 44 |
| 2015 May | 31 | 20 | 51 |
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