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Background. Primary aortic thrombus is an uncommon entity and not frequently reported in the literature. Herein, we discuss the presentation and management of a patient with a primary thoracic mural thrombus. Case Summary. A 46-year-old female with past medical history of tobacco dependence presented for low-grade fever and sudden onset, severe right upper quadrant abdominal pain with associated nausea and vomiting. Computed tomography (CT) revealed an intraluminal polypoid filling defect arising from the isthmus of the aorta projecting into the proximal descending aorta and findings consistent with infarction of the spleen and right kidney. Infectious, autoimmune, hematologic, and oncologic work-up were all unyielding. The patient was started on heparin and later transitioned to apixaban 5 mg twice a day and 81 mg of aspirin daily. She was also counseled regarding smoking cessation. Two months follow-up CT revealed resolution of the thrombus. Patient had no further thromboembolic complications. Discussion. We present a unique case of primary aortic thrombus. To our knowledge, this is the first reported case managed successfully with a NOAC. This diagnosis is one of exclusion and through work-up should be completed. Our aim is to raise awareness of this condition and successful management with apixaban in low-risk patients.

Myxomas are the most common benign cardiac neoplasms in adults. The vast majority of cardiac myxomas arise from the left atrium near the fossa ovalis of the intra-atrial septum. There have been reports of myxomas arising from the ventricles accounting for about 5% of cases. In our literature review, we have found 55 reported cases of myxomas originating from the mitral valve reported in the adult population dating back to 1871. The majority of these cases presented with embolic complications or syncope. We present an incidental mitral valve myxoma which we excised in efforts to prevent debilitating complications.

Accurate assessment of volume status is critical in the management of patients with heart failure (HF). We studied the utility of a pocket-sized ultrasound device in an outpatient cardiology clinic as a tool to guide volume assessment. Inferior vena cava (IVC) size and collapsibility were assessed in 95 patients by residents briefly trained in focused cardiac ultrasound (FCU). Cardiologist assessment of volume status and changes in diuretic medication were also recorded. Patients were followed for occurrence of 30-day events. There was a 94% success rate of obtaining IVC size and collapsibility, and agreement between visual and calculated IVC parameters was excellent. Most patients were euvolemic by both FCU IVC and clinical bedside assessment (51%) and had no change in diuretic dose. Thirty-two percent had discrepant FCU IVC and clinical volume assessments. In clinically hypervolemic patients, the FCU evaluation of the IVC suggested that the wrong diuretic management plan might have been made 46% of the time. At 30 days, 14 events occurred. The incidence of events increased significantly with FCU IVC imaging categorization, from 11% to 23% to 36% in patients with normal, intermediate, and plethoric IVCs. By comparison, when grouped in a binary manner, there was no significant difference in event rates for patients who were deemed to be clinically volume overloaded. Assessment of volume status in an outpatient cardiology clinic using FCU imaging of the IVC is feasible in a high percentage of patients. A group of patients were identified with volume status discordant between FCU IVC and routine clinic assessment, suggesting that IVC parameters may provide a valuable supplement to the in-office physical examination.

Introduction: Accurate assessment of volume status is critical in the management of patients with congestive heart failure (CHF). We studied the utility of a pocket sized ultrasound device (Vscan; GE) in an outpatient cardiology clinic as a tool to guide volume assessment and reduce CHF admissions. Hypothesis: Use of pocket ultrasound to assess IVC parameters will help clinicians titrate diuretic medications and decrease hospital admissions. Methods: Inferior vena cava (IVC) maximum size and collapsibility were assessed in 95 patients by two internal medicine residents briefly trained in focused cardiac ultrasound (FCU). Both visual estimation and quantification of IVC size and collapsibility were performed during passive respiration and inspiratory sniff. Patients with IVC size O2cm and collapsibility !50% were deemed volume overloaded. Cardiologist assessment of volume status (blinded to imaging data) and changes in diuretic medication were also recorded. Patients were followed by means of chart review and telephone inquiry for occurrence of 30 day events (ER visit or hospital admission). Results: There was a 95% success rate of obtaining IVC size and collapsibility. Agreement between the visual and calculated IVC assessments of collapsibility and size were excellent, kappa 0.96 (95% CI: 0.89-1.00) and 0.87 (95% CI: 0.745-0.99), respectively, resulting in a 93% concordance for volume status assessment. Comparison of visual IVC and clinician ability to detect volume overload yielded a kappa statistic of 0.25 (95% CI: -0.01 0.51). Most patients were euvolemic by both IVC and clinician assessment (83%); only 2% were overloaded by both techniques. In 14% of patients there was discordance in volume status between visual IVC and clinician assessment, most of whom (11/ 12) were volume overloaded by IVC. In these 11 patients, 10 did not have their diuretic dose increased. At 30 days, 14 events occurred, with volume assessment discordant in 4. Two events were CHF-related and volume assessment was not discordant in either case. Of the other 12 events, half were cardiovascular and half were non-cardiovascular. Conclusion: Assessment of volume status in an outpatient cardiology clinic using FCU imaging of the IVC is feasible in a high percentage of patients. The strong agreement between visually assessed and measured IVC parameters validates FCU as a quick subjective bedside tool. Most patients in this outpatient cohort were euvolemic by both IVC and clinician. A group of patients was identified as volume overloaded by IVC yet euvolemic by clinician, suggesting that FCU in an outpatient setting may be a valuable adjunct to the physical exam. Whether FCU can help prevent hospital admission warrants further study in a larger patient population.