Asian Cardiovasc Thorac Ann 2008;16:e35-e36
© 2008 Asia Publishing EXchange Ltd
Right Atrial Thrombus Masquerading as Intracardiac Cyst: a Case Report
Arvind V Singh, FRCS,
John T Walsh, FRCP1,
Inderpaul S Birdi, FRCS CTh
Department of Cardiothoracic Surgery Trent Cardiac Center Nottingham City Hospital
1 Department of Cardiology Queen’s Medical Center University Hospital NHS Trust Nottingham, United Kingdom
For reprint information contact: Arvind V Singh, FRCS Tel : 44 115 969 1169 Fax : 44 115 840 2605 Email: arvindvsingh{at}yahoo.com, Department of Cardiothoracic Surgery, Trent Cardiac Center, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB United Kingdom.
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ABSTRACT
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Intracardiac cystic lesions are rare. Hydatid disease, blood cysts and bronchogenic cysts in various chambers of the heart have been reported. Right atrial thrombus presenting as a cystic lesion on echocardiogram has not been reported. We describe a patient with mitral regurgitation in atrial fibrillation with a right atrial cyst, which was found to be a cavitating thrombus.
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INTRODUCTION
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Cystic lesions are a rare cause of intracardiac masses. Cardiac hydatidosis represents 0.5%–2% of human echinococcous presentations.1 Other causes of intracardiac cysts reported have been blood and epithelial cysts.2
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3 We report a case of right atrial cystic lesion, which was actually a thrombus, in a patient with mitral regurgitation in atrial fibrillation.
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CASE REPORT
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A 70-year-old Pakistani gentleman, with longstanding mitral regurgitation and permanent atrial fibrillation presented with progressive dyspnea. In the preceding three months he had atypical chest pain without ischemia and temporary left lower limb monoparesis. Grade IV pansystolic murmur was audible at the apex. Echocardiogram revealed anterior mitral leaflet prolapse with severe mitral regurgitation and hypertrophied left ventricle with mildly impaired systolic function. A cyst 6 x 5 x 3 cm was seen attached to the right atrial free wall (Figure 1
). Cardiac hydatid disease was therefore suspected. Angiogram showed normal coronaries. Computed tomography of head, thorax and abdomen showed a 0.5 cm hemorrhagic lesion in the right occipital lobe which was confirmed as hemorrhagic by magnetic resonance imaging. Other viscera were normal. Serologic tests for echinococcous were negative. Albendazole treatment was commenced due to high index of clinical suspicion. Four weeks later an intraoperative transesophageal echocardiogram confirmed previous findings. Cardiopulmonary bypass was established with aortic and bicaval cannulation, without disturbing the right atrial lesion. Heart was arrested with antegrade warm blood followed by cold blood cardioplegia and vena cavae were snared. The right atrium was opened and the lesion on free wall of the right atrium was excised intact (Figure 2). The appendage was free of clots. A small thrombus was seen at the coronary sinus opening and was removed. The right atrium was closed. The mitral valve was approached after incising the left atrium lateral to the interatrial groove. The left atrium was free of thrombus. The mitral valve was repaired with neochordae using 4/0 Gore-Tex sutures. Annuloplasty was performed with a size 30 Carpentier Edwards physio ring. The left atrium was closed. Heart was deaired prior to reperfusion. The patient was weaned from cardioplulmonary bypass with atrio-ventricular sequential pacing without inotropes. Post-bypass transesophageal echocardiogram confirmed good mitral valve repair without mitral regurgitation. Postoperatively, he was re-explored for bleeding, revealing no surgical source. Bleeding finally stopped with plasma and platelet transfusion. He developed fast atrial fibrillation, which was controlled with bisoprolol. The patient was discharged on the 10th postoperative day with warfarin, spironolactone, frusemide and ramipril. A biopsy of right atrial lesion confirmed a thrombus without evidence of malignancy or hydatid disease.
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DISCUSSION
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Intracardiac cysts can have significant effects due to their location causing obstruction to blood flow, impingement of valve function or conduction system. Cardiac hydatidosis is an important clinical entity due to potential fatal complications. Hydatid cysts in the right atrial wall comprise 3%–4% of all cardiac echinococcal cysts. Right-sided cardiac hydatid cysts have been reported to cause fatal pulmonary embolism.1 A history of frequent travel to Pakistan in our patient made us consider a diagnosis of hydatid cyst. The primary cardiac disease here was mitral regurgitation with atrial fibrillation.
A history of monoparesis with spontaneous resolution in a few hours and the finding of hemorrhagic lesion in the right occipital lobe were both suggestive of embolic phenomena but there was no clot in the left atrium. Thrombi formed due to atrial fibrillation are usually located in the appendage whereas this lesion was attached to the right atrial free wall. Moreover, primary right atrial thrombus is infrequent and is usually due to a foreign body in the right atrium, like devices for central venous access and pacemaker leads.4
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5 Malignancy, especially renal cell carcinoma can manifest similarly due to extension of inferior vena cava tumor thrombus.5 In systemic disorders like Behcet’s disease and heparin-induced thrombocytopenia with thrombosis, it forms a part of prothrombotic state with thromboembolic events occurring elsewhere in the body.6
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Though the right atrial lesion in our patient turned out to be a thrombus, the echocardiographic picture was that of a cyst. Computed tomography and magnetic resonance imaging are useful in providing information about the nature of the mass and its exact location.8 If cardiac hydatidosis is suspected, it has implications in preoperative preparation and intraoperative handling of the heart. It is very important that cardiopulmonary bypass is established with minimum handling of the heart. The cyst is excised intact for the fear of fatal rupture leading to anaphylaxis or pulmonary embolism.
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ACKNOWLEDGMENTS
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We acknowledge Ms Emma Downing in Medical Photography for processing the images for this article.
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REFERENCES
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- Kaplan M, Demirtas M, Cimen S, Ozler A. Cardiac hydatid cysts with intracavitary expansion. Ann Thorac Surg 2001;71:1587–90[Abstract/Free Full Text]
- Roberts PF, Serra AJ, McNicholas KW, Shapira N, Lemole GM. Atrial blood cyst: a rare finding. Ann Thorac Surg 1996;62:880–2.[Abstract/Free Full Text]
- Scheimberg I, Rose S, Malone M. Intracardiac epithelial cyst associated with esophageal atresia. Pediatr Pathol Lab Med 1997;17:945–9.[Medline]
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- Coleman DB, DeBarr DM, Morales DL, Spotnitz HM. Pacemaker lead thrombosis treated with atrial thrombectomy and biventricular pacemaker and defibrillator insertion. Ann Thorac Surg 2004;78:e83–4.[Abstract/Free Full Text]
- Kaneko Y, Tanaka K, Yoshizawa A, Yasuoka H, Suwa A, Satoh T, et al. Successful treatment of recurrent intracardiac thrombus in Behcet’s disease with immunosuppressive therapy. Clin Exp Rheumatol 2005;23:885–7.[Medline]
- Morgan JA, Kherani AR, Vigilance DW, Cheema FH, Colletti NJ, Sahar DI, et al. Off-pump right atrial thrombectomy for heparin-induced thrombocytopenia with thrombosis. Ann Thorac Surg 2003;76:615–7.[Abstract/Free Full Text]
- Kanadasi M, Demirtas M, San M, Ozer C, Soyupak SK, Kisacikoglu B. Mobile right atrial hydatid cyst with multiorgan involvement. Catheter Cardiovasc Interv 2000;49:204–7.[Medline]
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