A journey through anticoagulant therapies in the treatment of left ventricular thrombus in post-COVID-19 heparin-induced thrombocytopenia: a case report

BACKGROUND

Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug reaction associated with thrombosis. Clinical scoring systems and the presence of anti-platelet factor 4 (anti-PF4)/heparin antibodies determine the diagnosis.

CASE PRESENTATION

A 57-year-old man who was treated with acenocoumarol due to a chronic left ventricular thrombus was admitted to the hospital for severe SARS-CoV-2 pneumonia and pulmonary embolism. The patient was started on bemiparin and discharged. Left lower limb acute arterial ischemia and thrombocytopenia were diagnosed 18 days later. Computed tomography angiography revealed a large left ventricular thrombus and multiple arterial thrombi. Left femoral-popliteal thromboembolectomy was performed. Anti-PF4/heparin antibodies confirmed an HIT diagnosis. Fondaparinux (7.5 mg/24 h) was initiated, but cardiac surgery was necessary. Bivalirudin was used during surgery, with an initial load (1.25 mg/kg) and maintenance infusion (2.5 mg/kg/h). The cardiac thrombus was extracted, but the patient experienced a postsurgical myocardial infarction. Percutaneous cardiovascular intervention (PCI) required a bivalirudin load (0.75 mg/kg) and maintenance infusion (1.75 mg/kg/h). No coronary lesions were detected, and argatroban was started afterwards (0.5 µg/kg/min). When the platelet count exceeded 100 × 10⁹/L, acenocoumarol was initiated. Thereupon, acetylsalicylic acid (100 mg/24 h) was added. No other complications have been reported to date.

CONCLUSION

The clinical presentation of intraventricular and multiple arterial thrombi is remarkable. SARS-CoV-2 infection likely contributed to a hypercoagulable state. The management of patients with HIT undergoing cardiac surgery is challenging. If surgery cannot be delayed, then treatment with bivalirudin is recommended. Additionally, this drug is recommended for PCI. Bivalirudin is safe and well-tolerated in both procedures.

Human Cardiac Mesenchymal Stromal Cells From Right and Left Ventricles Display Differences in Number, Function, and Transcriptomic Profile

BACKGROUND

Left ventricle (LV) and right ventricle (RV) are characterized by well-known physiological differences, mainly related to their different embryological origin, hemodynamic environment, function, structure, and cellular composition. Nevertheless, scarce information is available about cellular peculiarities between left and right ventricular chambers in physiological and pathological contexts. Cardiac mesenchymal stromal cells (C-MSC) are key cells affecting many functions of the heart. Differential features that distinguish LV from RV C-MSC are still underappreciated.

AIM

To analyze the physiological differential amount, function, and transcriptome of human C-MSC in LV versus (vs.) RV.

METHODS

Human cardiac specimens of LV and RV from healthy donors were used for tissue analysis of C-MSC number, and for C-MSC isolation. Paired LV and RV C-MSC were compared as for surface marker expression, cell proliferation/death ratio, migration, differentiation capabilities, and transcriptome profile.

RESULTS

Histological analysis showed a greater percentage of C-MSC in RV vs. LV tissue. Moreover, a higher C-MSC amount was obtained from RV than from LV after isolation procedures. LV and RV C-MSC are characterized by a similar proportion of surface markers. Functional studies revealed comparable cell growth curves in cells from both ventricles. Conversely, LV C-MSC displayed a higher apoptosis rate and RV C-MSC were characterized by a higher migration speed and collagen deposition. Consistently, transcriptome analysis showed that genes related to apoptosis regulation or extracellular matrix organization and integrins were over-expressed in LV and RV, respectively. Besides, we revealed additional pathways specifically associated with LV or RV C-MSC, including energy metabolism, inflammatory response, cardiac conduction, and pluripotency.

CONCLUSION

Taken together, these results contribute to the functional characterization of RV and LV C-MSC in physiological conditions. This information suggests a possible differential role of the stromal compartment in chamber-specific pathologic scenarios.

Stereological estimates of nuclear number in human ventricular cardiomyocytes before and after birth obtained using physical disectors

Design-based stereology is employed to estimate total numbers of myocyte nuclei and mean myocyte volume per nucleus in ventricles of fetal and early postnatal human hearts. Organs were collected postmortem from subjects varying in age from 16 gestational wk to 40 postnatal wk. Numbers of myocyte nuclei per unit volume of ventricle were estimated using physical disectors (parallel pairs of sections). Absolute numbers were calculated by multiplying nuclear packing densities by ventricular volumes estimated from ventricular mass and tissue density. Volumes per nucleus were obtained via estimates of the combined volumes of all myocytes (or of the myocardium as a whole) and the numbers of myocyte nuclei. The findings showed that numbers of myocyte nuclei increase linearly from 16 wk towards term. They were also consistent with the notion that hyperplasia ceases abruptly at birth or soon afterwards. The net rate of production of myocyte nuclei was about 38 x 10(7)/wk (2.3 million nuclei/h). The total volume of myocytes continued to expand in the same way from 16 wk to at least 35 wk of gestation. Published studies on the incidence of binucleate myocytes during early postnatal growth of the ventricles of rats suggest that the volume of a myocyte doubles prior to nuclear division. Prenatal growth in the human heart is consistent with this mechanism. Myocardial hypertrophy after birth must occur by cellular hypertrophy without karyokinesis.