Transcatheter Arterial Embolization as a Treatment for Life-Threatening Retroperitoneal Hemorrhage in COVID-19 Patients on Anticoagulant Therapy

Retroperitoneal hemorrhage is a possible complication that has been noticed in COVID-19 patients on anticoagulant therapy. The data related to treatment and outcomes in this condition are scarce. We present a case series of four COVID-19 patients with lumbar artery bleeding, who were treated with transcatheter arterial embolization using embolization particles. The procedure was executed without any complications, and hemostasis was achieved in all four patients. Despite the patients survived the procedure, one patient died due to respiratory failure three weeks after the procedure, and one died due to hypovolemic shock two days later. Considering the ongoing state of COVID-19 pandemic, it is essential to be aware of transcatheter arterial embolization as a safe and effective procedure for treating retroperitoneal hemorrhage in COVID-19 patients.

Establishment of a nomogram model for predicting therapy complications in patients with polycythemia and deep venous thrombosis

BACKGROUND Patients with deep venous thrombosis(DVT)residing at high altitudes can only rely on anticoagulation therapy,missing the optimal window for surgery or thrombolysis.Concurrently,under these conditions,patient outcomes can be easily complicated by high-altitude polycythemia(HAPC),which increases the difficulty of treatment and the risk of recurrent thrombosis.To prevent reaching this point,effective screening and targeted interventions are crucial.Thus,this study analyzes and provides a reference for the clinical prediction of thrombosis recurrence in patients with lower-extremity DVT combined with HAPC.AIM To apply the nomogram model in the evaluation of complications in patients with HAPC and DVT who underwent anticoagulation therapy.METHODS A total of 123 patients with HAPC complicated by lower-extremity DVT were followed up for 6-12 months and divided into recurrence and non-recurrence groups according to whether they experienced recurrence of lower-extremity DVT.Clinical data and laboratory indices were compared between the groups to determine the influencing factors of thrombosis recurrence in patients with lowerextremity DVT and HAPC.This study aimed to establish and verify the value of a nomogram model for predicting the risk of thrombus recurrence.RESULTS Logistic regression analysis showed that age,immobilization during follow-up,medication compliance,compliance with wearing elastic stockings,and peripheral blood D-dimer and fibrin degradation product levels were indepen-dent risk factors for thrombosis recurrence in patients with HAPC complicated by DVT.A Hosmer-Lemeshow goodness-of-fit test demonstrated that the nomogram model established based on the results of multivariate logistic regression analysis was effective in predicting the risk of thrombosis recurrence in patients with lowerextremity DVT complicated by HAPC(χ^(2)=0.873;P>0.05).The consistency index of the model was 0.802(95%CI:0.799-0.997),indicating its good accuracy and discrimination.CONCLUSION The column chart model for the personalized prediction of thrombotic recurrence risk has good application value in predicting thrombotic recurrence in patients with lower-limb DVT combined with HAPC after discharge.

Challenging anticoagulation therapy for multiple primary malignant tumors combined with thrombosis:A case report and review of literature

BACKGROUND Venous thromboembolism significantly contributes to patient deterioration and mortality.Management of its etiology and anticoagulation treatment is intricate,necessitating a comprehensive consideration of various factors,including the bleeding risk,dosage,specific anticoagulant medications,and duration of therapy.Herein,a case of lower extremity thrombosis with multiple primary malignant tumors and high risk of bleeding was reviewed to summarize the shortcomings of treatment and prudent anticoagulation experience.CASE SUMMARY An 83-year-old female patient was admitted to the hospital due to a 2-wk history of left lower extremity edema that had worsened over 2 d.Considering her medical history and relevant post-admission investigations,it was determined that the development of left lower extremity venous thrombosis and pulmonary embolism in this case could be attributed to a combination of factors,including multiple primary malignant tumors,iliac venous compression syndrome,previous novel coronavirus infection,and inadequate treatment for prior thrombotic events.However,the selection of appropriate anticoagulant medications,determination of optimal drug dosages,and establishment of an appropriate duration of anticoagulation therapy were important because of concurrent thrombocytopenia,decreased quantitative fibrinogen levels,and renal insufficiency.CONCLUSION Anticoagulant prophylaxis should be promptly initiated in cases of high-risk thrombosis.Individualized anticoagulation therapy is required for complex thrombosis.

Acute upper gastrointestinal bleeding in patients on long-term oral anticoagulation therapy: Endoscopic findings, clinical management and outcome

AIM: Acute gastrointestinal bleeding is a severe complication in patients receiving long-term oral anticoagulant therapy. The purpose of this study was to describe the causes and clinical outcome of these patients. METHODS: From January 1999 to October 2003, 111 patients with acute upper gastrointestinal bleeding (AUGIB) were hospitalized while on oral anticoagulants. The causes and clinical outcome of these patients were compared with those of 604 patients hospitalized during 2000-2001 with AUGIB who were not taking warfarin. RESULTS: The most common cause of bleeding was peptic ulcer in 51 patients (45%) receiving anticoagulants compared to 359/604 (59.4%) patients not receiving warfarin (P<0.05). No identifiable source of bleeding could be found in 33 patients (29.7%) compared to 31/604 (5.1%) patients not receiving anticoagulants (P=0.0001). The majority of patients with concurrent use of non-steroidal anti-inflammatory drugs (NSAIDs) (26/35, 74.3%) had a peptic ulcer as a cause of bleeding while 32/76 (40.8%) patients not taking a great dose of NSAIDs had a negative upper and lower gastrointestinal endoscopy. Endoscopic hemostasis was applied and no complication was reported. Six patients (5.4%) were operated due to continuing or recurrent hemorrhage, compared to 23/604 (3.8%) patients not receiving anticoagulants. Four patients died, the overall mortality was 3.6% in patients with AUGIB due to anticoagulants, which was not different from that in patients not receiving anticoagulant therapy. CONCLUSION: Patients with AUGIB while on long-term anticoagulant therapy had a clinical outcome, which is not different from that of patients not taking anticoagulants. Early endoscopy is important for the management of these patients and endoscopic hemostasis can be safely applied.

Use of MLC901 in cerebral venous sinus thrombosis:Three case reports

BACKGROUND Cerebral venous sinus thrombosis(CVT)is rare cause of cerebrovascular disease.The incidence is 0.5%of all stroke.The majority of affected patients are young adults(mean age:35-40 years)with mild to moderate disabilities.Poor outcome with severe disability is seen in 13%of cases.Early diagnosis and treatment are important for good outcomes and preventing complications.Treatment options are limited and mostly based on consensus.NeuroAiD II™(MLC901;Moleac Pte,Ltd,Singapore)has a potential beneficial role in post-stroke recovery,by aiding the natural brain recovery process.CASE SUMMARY MLC901 consists of nine natural herbal ingredients.Studies have shown its safety profile and aid in post stroke recovery.The aim of this case series was to demonstrate the potential role of MLC901 in stroke recovery of patients with cerebral venous sinus thrombosis(CVST)who received MLC901 in addition to standard of care.The prescribed dose of MLC901 is 400 mg/cap two capsules,three times a day.Data from these patients were prospectively collected at baseline and at monthly visits,for a duration of 3 mo.Outcome measures included adherence to therapy,side effects,National Institutes of Health Stroke Scale,Glasgow Coma Scale,modified Rankin Scale,and the Short Orientation-Memory-Concentration Test.MLC901 was well tolerated and no side effects were reported.All patients were stable with improved condition.CONCLUSION This case series highlights the potential therapeutic effects of MLC901 on CVST and provides support for further studies.

Safety of laparoscopic surgery in digestive diseases with special reference to antithrombotic therapy: A systematic review of the literature

AIMTo elucidate the effect of antithrombotic therapy （ATT） on bleeding and thromboembolic complications during or after laparoscopic digestive surgery.METHODSPublished articles or internationally accepted abstracts between 2000 and 2017 were searched from PubMed, Cochrane Database, and Google Scholar, and studies involving laparoscopic digestive surgery and antiplatelet therapy （APT） and/or anticoagulation therapy （ACT） were included after careful review of each study. Data such as study design, type of surgical procedures, antithrombotic drugs used, and surgical outcome （both bleeding and thromboembolic complications） were extracted from each study.RESULTSThirteen published articles and two internationally accepted abstracts were eligible for inclusion in the systematic review. Only one study concerning elective laparoscopic cholecystectomy in patients with peri-operative heparin bridging for ACT showed that the risk of postoperative bleeding was higher compared with those without ACT. The remaining 14 studies reported no signifcant differences in the incidence of bleeding complications between the ATT group and the group without ATT. The risk of thromboembolic events （TE） associated with laparoscopic digestive surgery in patients receiving ATT was not signifcantly higher than those with no ATT or interrupted APT.Fujikawa T et al . Laparoscopic digestive surgery and antithrombotic therapyCONCLUSIONLaparoscopic digestive surgery in ATT-burdened patients for prevention of bleeding and TE showed satisfactory results. The risk of hemorrhagic complication during or after these procedures in patients with continued APT or heparin bridging was not signifcantly higher than in patients with no ATT or interrupted APT.

Safety of pancreatic surgery with special reference to antithrombotic therapy:A systematic review of the literature

BACKGROUND Postpancreatectomy hemorrhage(PPH)is the most severe type of complication after pancreatic surgery,although the effect of antithrombotic therapy(ATT)on PPH is largely unknown.The safety and efficacy of chemical thromboprophylaxis for venous thromboembolism(VTE)remains controversial.AIM To elucidate the effect of ATT on PPH.METHODS Published articles between 2013 and 2020 were searched from PubMed and Google Scholar,and after careful reviewing of all studies,studies concerning ATT and pancreatic surgery were included.Data such as study design,type of surgical procedures,type of antithrombotic drugs,and surgical outcome were extracted from the studies.RESULTS Nineteen published articles with a total of 37863 patients who underwent pancreatic surgery were included in the systematic review.Fourteen were cohort studies,with only three being prospective in nature.Two studies demonstrated that in patients receiving chronic ATT,which were mostly managed by heparin bridging,the risk of PPH was higher compared with those without ATT,and one study showed that patients with direct-acting oral anticoagulants managed by heparin bridging had significantly higher postoperative bleeding rates than others.The remaining six studies reported that pancreatic surgery can be safely performed in patients receiving chronic ATT,even under preoperative aspirin continuation.Concerning chemical thromboprophylaxis for VTE,most studies have shown a potentially high risk of PPH in patients undergoing chemical thromboprophylaxis;however,its effectiveness against VTE has not been statistically demonstrated,particularly among Asian patients.CONCLUSION Pancreatic surgery in chronically ATT-received patients can be safely performed without an increase in the occurrence of PPH,although the safety and efficacy of chemical thromboprophylaxis for VTE during pancreatic surgery is still controversial.Further investigation using reliable studies with good design is required to establish definite protocols or guidelines.

Low-intensity anticoagulation therapy in the pregnant women with mechanical heart valves:a report with 56 cases

Objective To evaluate the method of low-intensity anticoagulation therapy in the pregnant women who had received mechanical heart valve replacemant,and the effects of warfarin on the pregnant women and their fetus. Methods This retrospective study involved 56 pregnant women (61 pregnancies) who had received mechanical heart valve replacement. Their pregnant status,delivery, and anticoagulation therapy were observed

Antithrombin Ⅲ deficiency in a patient with recurrent venous thromboembolism:A case report

BACKGROUND Antithrombin Ⅲ(AT3)deficiency,an autosomal dominant disease,increases the likelihood of an individual developing venous thromboembolism(VTE).Longterm anticoagulation treatment is required for those suffering from AT3 deficiency.CASE SUMMARY A man aged 23,who had a history of deep venous thrombosis(DVT),experienced recurrent pain and swelling in his right lower extremity for three days following withdrawal of Rivaroxaban.He was diagnosed with DVT and antithrombin Ⅲ deficiency as genetic testing revealed a single nucleotide variant in SERPINC1(c.667T>C,p.S223P).The patient was advised to accept long-term anticoagulant therapy.CONCLUSION Inherited AT3 deficiency due to SERPINC1 mutations results in recurrent VTE.Patients may benefit from long-term anticoagulant therapy.

Hemorrhagic shock due to submucosal esophageal hematoma along with mallory-weiss syndrome:A case report

BACKGROUND Esophageal submucosal hematoma is a rare condition.Although the exact etiology remains uncertain,vessel fragility with external factors is believed to have led to submucosal bleeding and hematoma formation;the vessel was ruptured by a sudden increase in pressure due to nausea,and the hematoma was enlarged by antiplatelet or anticoagulant therapy.Serious conditions are rare,with a better prognosis.We present the first known case of submucosal esophageal hematoma-subsequent hemorrhagic shock due to Mallory-Weiss syndrome.CASE SUMMARY A 73-year-old female underwent endovascular treatment for an unruptured cerebral aneurysm.The patient received aspirin and clopidogrel before surgery and heparin during surgery,and was well during the surgery.Several hours after returning to the ICU,she complained of chest discomfort,vomited 500 m L of fresh blood,and entered hemorrhagic shock.Esophageal submucosal hematoma with Mallory-Weiss syndrome was diagnosed through an endoscopic examination and computed tomography.In addition to a massive fluid and erythrocyte transfusion,we performed a temporary compression for hemostasis with a Sengstaken-Blakemore(S-B)tube.Afterwards,she became hemodynamically stable.On postoperative day 1,we performed an upper gastrointestinal endoscopy and confirmed no expansion of the hematoma nor any recurring bleeding;therefore,we removed the S-B tube and clipped the gastric mucosal laceration at the esophagogastric junction.We started oral intake on postoperative day 10.The patient made steady progress,and was discharged on postoperative day 33.CONCLUSION We present the first known case of submucosal esophageal hematoma subsequent hemorrhagic shock due to Mallory-Weiss syndrome.

possible role of soluble fibrin monomer complex after gastroenterological surgery

AIM To examine the role of soluble fibrin monomer complex(SFMC) in the prediction of hypercoagulable state after gastroenterological surgery.METHODS We collected data on the clinical risk factors and fibrin-related makers from patients who underwent gastroenterological surgery at Hiroshima University Hospital between April 1, 2014 and March 31, 2015. We investigated the clinical significance of SFMC, which is known to reflect the early plasmatic activation of coagulation, in the view of these fibrin related markers.RESULTS A total of 123 patients were included in the present study. There were no patients with symptomatic VTE. Thirty-five(28%) patients received postoperative anticoagulant therapy. In the multivariate analysis, a high SFMC level on POD 1 was independently associated with D-dimer elevation on POD 7(OR = 4.31, 95%CI: 1.10-18.30, P = 0.03). The cutoff SFMC level was 3.8 μg/ml(AUC = 0.78, sensitivity, 63%, specificity, 89%). The D-dimer level on POD 7 was significantly reduced in high-SFMC patients who received anticoagulant therapy in comparison to highSFMC patients who did not.CONCLUSION The SFMC on POD 1 strongly predicted the hypercoagulable state after gastroenterological surgery than the clinical risk factors and the other fibrin related markers.

Common carotid arterial thrombosis associated with ulcerative colitis

A 26-year-old woman with ulcerative colitis was transferred to our hospital with left hemiparesis due to cerebral infarction. Cervical ultrasonography and magnetic resonance imaging angiography revealed thrombosis at the right common carotid artery and the right internal carotid artery. Antithrombotic and anticoagulant therapies were commenced. After about 2 wk of the treatment, the frequency of her diarrhea increased. She underwent emergency subtotal colectomy, but 10 d later an abundant hemorrhage from the remnant rectum occurred, so the remnant rectum was resected and an ileal pouch anal anastomosis was performed. Antithrombotic and anticoagulant therapies were continued, but neither her neurological status nor magnetic resonance imaging angiography findings showed subsequent changes. She was discharged 3 mon after operation. This is a rare case of common carotid arterial thrombosis occurring as a complication of ulcerative colitis, in which antithrombotic and anticoagulant therapies are considered to provoke a deterioration of the patient’s bowel disease.

Prospective validation to prevent symptomatic portal vein thrombosis after liver resection

BACKGROUND Portal vein thrombosis(PVT)after liver resection is rare but can lead to lifethreatening liver failure.This prospective study evaluated patients using contrastenhanced computed tomography(E-CT)on the first day after liver resection for early PVT detection and management.AIM To evaluate patients by E-CT on the first day after liver resection for early PVT detection and immediate management.METHODS Patients who underwent liver resection for primary liver cancer from January 2015 were enrolled.E-CT was performed on the first day after surgery in patients undergoing anatomical resection,multiple resections,or with postoperative bile leakage in the high-risk group for PVT.When PVT was detected,anticoagulant therapy including heparin,warfarin,and edoxaban was administered.E-CT was performed monthly until PVT resolved.RESULTS The overall incidence of PVT was 1.57%(8/508).E-CT was performed on the first day after surgery in 235 consecutive high-risk patients(165 anatomical resections,74 multiple resections,and 28 bile leakages),with a PVT incidence of 3.4%(8/235).Symptomatic PVT was not observed in the excluded cohort.Multivariate analyses revealed that sectionectomy was the only independent predictor of PVT[odds ratio(OR)=12.20;95%confidence interval(CI):2.22-115.97;P=0.003].PVT was found in the umbilical portion of 75.0%(6/8)of patients,and sectionectomy on the left side showed the highest risk of PVT(OR=14.10;95%CI:3.17-62.71;P<0.0001).CONCLUSION Sectionectomy on the left side should be chosen with caution as it showed the highest risk of PVT.E-CT followed by anticoagulant therapy was effective in managing early-phase PVT for 2 mo without adverse events.

Research advances of Chinese and Western medicine in the treatment of unexplained recurrent spontaneous abortion

Recurrent spontaneous abortion is a common disease in gynecology,and it seriously affects women's reproductive health and brings heavy burden and pain to society and families.The cause of recurrent spontaneous abortion is complicated,in addition to the well-defined genetic,anatomical,infection and endocrine factors,and there are still some unknown causes,which is called as unexplained recurrent spontaneous abortion,accounting for 40%of recurrent abortion.At present,there are a lot of researches on the treatment methods of the patients with the unexplained recurrent spontaneous abortion,which also shows that the treatment of traditional Chinese and Western medicine all have certain clinical application effect.Western medicine clinical methods mainly includes immunotherapy,immunosuppressive therapy,anticoagulation therapy,progesterone therapy,etc.Based on the experience of the professor and combined with many years of clinical practice,the author believes that the pathogenesis of this disease in traditional Chinese medicine is mainly due to impaired impulse and deficiency of Spleen,lack of qi and blood,can not nourishing the fetus;deficiency of Kidney Qi,blood flow was delayed,and blood stasis and could not raise the fetus.Clinical treatment is based on invigorating the kidney,tonifying spleen and nourishing blood,promoting blood circulation to remove blood stasis and dredging collaterals.Oral Chinese medicine combined with external acupuncture and moxibustion has achieved excellent effects in improving pregnancy rate.This article reviews the domestic and foreign methods of treating unexplained recurrent miscarriage in order to provide clinical reference.In the future,the combination of Chinese and Western medicine should become the main therapy to increase pregnancy rate.

Effectiveness and safety of antithrombotic strategies in elderly patients with acute myocardial infarction

BACKGROUND Elderly patients represent a rapidly growing part of the population more susceptible to acute coronary syndromes and their complications.However,literature evidence is lacking in this clinical setting.AIM To describe the clinical features,in-hospital management and outcomes of“elderly”patients with myocardial infarction treated with antiplatelet and/or anticoagulation therapy.METHODS This study was a retrospective analysis of all consecutive patients older than 80 years admitted to the Division of Cardiology of St.Andrea Hospital of Vercelli from January 2018 to December 2018 due to ST-elevation myocardial infarction(STEMI)or non-ST elevation myocardial infarction(NSTEMI).Clinical and laboratory data were collected for each patient,as well as the prevalence of previous or in-hospital atrial fibrillation(AF).In-hospital management,consisting of an invasive or conservative strategy,and the anti-thrombotic therapy used are described.Outcomes evaluated at 1 year follow-up included an efficacy ischemic endpoint and a safety bleeding endpoint.RESULTS Of the 105 patients enrolled(mean age 83.9±3.6 years,52.3%males),68(64.8%)were admitted due to NSTEMI and 37(35.2%)due to STEMI.Among the STEMI patients,34(91.9%)underwent coronary angiography and all of them were treated with percutaneous coronary intervention(PCI);among the NSTEMI patients,42(61.8%)were assigned to an invasive strategy and 16(38.1%)of them underwent a PCI.No significant difference between the groups was found concerning the prevalence of previous or in-hospital de-novo AF.10.5%of the whole population received triple antithrombotic therapy and 9.5%single antiplatelet therapy plus oral anticoagulation(OAC),with no significant difference between the subgroups,although a higher number of STEMI patients received dual antiplatelet therapy without OAC as compared with NSTEMI patients.A low rate of in-hospital death(5.7%)and 1-year cardiovascular death(3.3%)was registered.Seven(7.8%)patients experienced major adverse cardiovascular events,while the rate of minor and major bleeding at 1-year follow-up was 10%and 2.2%,respectively,with no difference between NSTEMI and STEMI patients.CONCLUSION In this real-world study,a tailored evaluation of an invasive strategy and antithrombotic therapy resulted in a low rate of adverse events in elderly patients hospitalized with acute myocardial infarction.

Atrial fibrillation and concomitant left subclavian, axillary and brachial artery embolism after fiberoptic bronchoscopy: A case report

BACKGROUND Fiberoptic bronchoscopy has been widely used in the diagnosis and treatment of respiratory diseases.Numerous major and minor complications have been reported following this procedure.The incidence of major postoperative complications is approximately 0.5%and includes respiratory depression,pneumothorax,pulmonary edema,pneumonia,airway obstruction and cardiorespiratory arrest.Minor complications include vasovagal reactions,cardiac arrhythmias,hemorrhage,pneumothorax,aphonia,nausea,vomiting and fever.However,to our knowledge,a case of atrial fibrillation(AF)concomitant with fatal arterial embolism in the upper extremities following diagnostic bronchoscopy has never been reported.CASE SUMMARY A 70-year-old female patient presented with a history of rheumatic heart disease beginning at 10 years of age and an approximately 10-year history of hypertension.The patient was transferred from the cardiology department to the respiratory department due to recurrent coughing,pneumonia,and fever.She underwent fiberoptic bronchoscopy in the respiratory department.Approximately 2 h after completion of bronchoscopy,she complained of left arm numbness and weakness.Physical examination detected cyanosis of the left upper extremity,grade III weakened limb muscle strength,and undetectable left brachial artery pulsation.Auscultation indicated AF.B-mode ultrasound examination of the blood vessels showed hyperechoic material in the left subclavian,axillary and brachial arteries,and parallel veins.As our hospital has no vascular surgery capability,the patient was transferred to a specialized hospital for emergency thrombectomy that day.A tracking investigation found that the patient’s conditions improved after successful thrombectomy.CONCLUSION Thromboembolism following bronchoscopy is rare,and only a few cases of cerebral air embolism after bronchoscopy have been reported.

Why the Partnership of OAT Italian Patients Association in Cosenza＇s Hospital Matters？

The activism of patients associations, in decision making, about health and social services, is an expanding phenomenon in Italy and elsewhere. But the civic roles of these patients associations, in health care settings, remain largely unexplored, especially in the case of patients assuming oral anticoagulant therapy （OAT Patients） for various chronic and severe diseases （stroke, chronic arthritis, maintenance or substitution of cardiac valves）. This is a qualitative study, on a Civic Health Organization, the Italian Association of Anti Coagulant Patients （Associazione ltaliana Pazienti Anticolagulati, hereinafter A.I.P.A.） which promotes the rights of OAT patients. The study was carried out in the south of Italy at Cosenza＇s Hospital. Cosenza is a city in the north of Calabria, a poor Southern Italian region. The research, done between March 2010 and December 2012, involved focus groups, key-informant interviews with volunteers from the local A.I.P.A. unit and the hospital professionals （physicians, nurses, managers） of Cosenza＇s Annunziata Hospital. This essay mainly analyzes a micro-form of co-deliberative health care democracy： a stable partnership between AIPA members and the cited hospital professionals, based on a mix of advocacy, planning, and co-delivery service roles. In doing this, the paper sketches the development, aims, activities, internal structure and resources, and the role played by this specific citizen-user/patient/career organization in promoting and/or representing the interests of anti-coagulated patients within the legal arena of the Italian health policy. Finally, the paper comes to the point in which OAT patients refer their perceptions of relational rights.

Left Ventricular “Horseshoe-Thrombus”—A Case Report

Thrombi represent the most frequently found intracardiac masses. Left ventricular thrombus (LVT) is an important complication in patients with ischemic heart diseases and in those with dilated cardiomyopathy and systolic heart failure. The diagnosis of left ventricular thrombus remains important since anticoagulation will reduce the risk of systemic embolization and stroke. Despite advances in other imaging modalities, echocardiography remains the most important tool for diagnosis and risk stratification in patients predisposed to develop left ventricular thrombi. Mural thrombi formed on the left ventricular endocardium and horseshoe-shaped in chronic dilated cardiomyopathy, masquerading as left ventricular endomyocardial fibrosis was diagnosed by transthoracic 2D echocardiographic imaging in a 38 years old middle aged man. Background of this case highlighted the pathophysiology, high risk echocardiographic features and the role of anticoagulant therapy in LV thrombus with dilated cardiomyopathy.

Is transesophageal echocardiography needed for evaluating tissue-based transient ischemic attack？

Transient ischemic attack（TIA） is a warning signal for stroke.A comprehensive evaluation of TIA may reduce the risk for subsequent stroke.Data on the findings of cardiac evaluation with transesophageal echocardiography（TEE） in patients with TIA are sparse.Our aims were to determine the frequency of TEE performance and to investigate the findings of TEE in patients with TIA based on the new definition of TIA（i.e.,transient neurological symptoms without evidence of infarction）.During a 4-year period（2011–2014）,1071 patients（mean age,70 ± 13 years;female,49.7%） with TIA were included in a prospective study and evaluated.Of 1071 consecutive patients suffering from TIA,288 patients（27%） underwent TEE.The median time between admission and TEE was 6 days.Patients with TIA who were evaluated by TEE were younger（67 vs.71 years,P 〈 0.001） than those who were not evaluated by TEE.They had a higher rate of sensibility disturbance as a TIA symptom（39% vs.31%,P = 0.012） but a lower rate of previous stroke（15% vs.25%,P = 0.001） and atrial fibrillation（2% vs.21%,P 〈 0.001） than those who did not.Foramen ovale was detected in 71 patients（25.7%）,atrial septal aneurysm in 13 patients（4.6%）,and severe atherosclerotic plaques（grade 4 and 5） in the aortic arch in 25 patients（8.7%）.One patient（0.3%） had a fibroma detected by TEE.In 17 of the 288 patients（6%） who underwent TEE,the indication for anticoagulation therapy was based on the TEE results,and 1 patient with fibroma underwent heart surgery.During hospitalization,7 patients experienced a subsequent stroke,and 27 patients had a recurrent TIA.At 3 months following discharge,the rates of readmission,stroke,recurrent TIA,and death were 19%,2.7%,4.2%,and 1.6%,respectively.The rates of mortality（0.9% vs.1.8%,P = 0.7）,stroke risk（1.9% vs.3.0%,P = 0.8）,and recurrent TIA（5.0% vs.3.9%,P = 0.8） were similar in patients who underwent TEE and in those who did not.Performing TEE in patients with tissue-based TIA is helpful in detecting cardiac sources for embolism and may indicate for anticoagulation.

Clinical considerations of anticoagulation therapy for patients with atrial fibrillation

Atrial fibrillation (AF) increases the risk of stroke. New anticoagulation agents have recently provided alternative and promising approaches. This paper reviews the current state of anticoagulation therapy in AF patients, focusing on various clinical scenarios and on comparisons, where possible, between western and eastern populations.