Free-floating right heart thrombus (RHT) is an extreme medical emergency in the context of acute massive pulmonary embolism (PE). Despite the advances in early diagnosis, the management is still very debatable due to lack of consensus. We reported the case of a 66-year-old male, with a history of moderate renal dysfunction and dilated cardiomyopathy, who presented to the emergency department for acute dyspnea. His angiographic magnetic resonance imaging revealed bilateral extensive PE. Transthoracic echocardiography showed RHT with moderate right ventricular dysfunction and pulmonary hypertension. Venous Doppler of the lower extremities noted the presence of a floating clot in the right common femoral vein. The patient was managed successfully by thrombolytic therapy with tenecteplase. To the best of our knowledge, this is the first case report of RHT and PE from Lebanon. Published cases from Middle Eastern countries are scarse.

BackgroundGuidelines suggest that patients discontinue Clopidogrel at least 5 days prior to coronary artery bypass grafting (CABG). Those with acute coronary syndrome (ACS) are at high risk for myocardial infarction (MI) if not treated with dual antiplatelet therapy (DAPT). We sought to assess pre and post-operative outcomes of patients maintained on Clopidogrel and aspirin up to the time of surgery and compare them with those on aspirin alone.MethodsFrom the cardiac surgery database, 240 patients were retrospectively registered between January and May 2017. There were 126 patients with ACS who underwent CABG on DAPT (Clopidogrel group [CG]) and 114 patients who underwent elective CABG on aspirin alone (control). The CG received intraoperative prophylactic platelet transfusion (PPT). Demographics, comorbidities, and laboratory data were prospectively entered at the time of surgery and were subsequently retrieved for analysis. Per and postoperative findings were identified and compared between both groups.ResultsThe cohort consisted of 240 patients (mean age 61 years, 81.3% were male, SD ± 9.58). Patients in the CG were younger (Median 57 vs. 63, P-value 0.001), and with male predominance (86% versus 75%, P-value 0.028). In addition, they had less prevalence for diabetes and renal failure as compared to control (P-values 0.003, and 0.005, respectively). There were no significant differences between both groups in number of vessels grafts, duration of on-pump and aortic clamp. Hematologic laboratory data had also similar baseline values. The CG had similar bleeding rate, redo surgery and in-hospital death (P-values non-significant), however more infection and total hospital stay as compared to control (p-values 0.048 and 0.001).ConclusionPatients who are at increased risk for MI can be maintained on DAPT up to the time of CABG because surgery is safe when patients are offered PPT.

Eosinophilic myocarditis (EM) is a rare subtype of myocarditis that is characterized by eosinophilic infiltration of the myocardium and is associated with peripheral eosinophilia in most cases. The diagnosis is suspected in the presence of acute myocarditis and peripheral eosinophilia and is usually confirmed by endomyocardial biopsy (EMB) before starting steroid therapy. Here, we present a case of severe idiopathic eosinophilic myocarditis in a young man with a history of asthma and peripheral eosinophilia. He was treated with high-dose steroids despite negative EMB, and we noted a dramatic improvement in cardiac function. Our case highlights the importance of cardiac magnetic resonance (CMR) and clinical judgment in establishing the diagnosis of EM irrespective of the histopathologic result.

Background The management of intermediate-high risk acute pulmonary embolism (PE) is controversial with increasing interest in more aggressive treatment approaches than anticoagulation alone. Case summary We describe the case series of four consecutive patients who presented to emergency room for acute shortness of breath. They were diagnosed with intermediate-high risk acute PE based on the computed tomography pulmonary angiography (CTPA) and transthoracic echocardiography (TEE) findings and the elevated simplified pulmonary embolism score index (sPESI). They received bolus of 5 mg thrombolytics (rtPA) administered through peripheral intravenous line followed by continuous infusion at a rate of 2 mg per hour along with unfractionnated heparin at a rate of 500 mg/hour for additional ≤ 10 hours. There after the dose of UFH was increased to reach a therapeutic level. Rapid clinical improvement and also improvement in TTE parameters were noted at discharge. Patients were discharged home on oral anticoagulation. Discussion Intermediate high risk acute PE carries increased risk of mortality and morbidities. CDT uses a low rtPA dose for local thrombolysis and is associated with low bleeding risk; however it is expensive and requires expertise and human resources. Low dose rtPA through a peripheral IV-line might be safe and effective in the treatment of patient with intermediate-high risk acute PE. This therapeutic approach is readily available at most medical centers, can be started in the ER, and can be alternative to CDT nowadays during the COVID-19 era and in hospitals at the periphery and with limited resources.