Asian Cardiovasc Thorac Ann 1999;7:233-235
© 1999 Asia Publishing EXchange Pte Ltd
Right Atrial Pedunculated Ball Thrombus
Takehiro Inoue, MD,
Masaki Otaki, MD,
Kwansong Ku, MD,
Tosihiko Saga, MD,
Hidetaka Oku, MD
Department of Cardiovascular Surgery
Kinki University School of Medicine
Osaka, Japan
|
|
For reprint information contact: Takehiro Inoue, MD Tel: 81 723 66 0221 Fax: 81 723 67 8657 email: rtc-ryo{at}med.kindai.ac.jp Department of Cardiovascular Surgery, Kinki University School of Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka 589-8511, Japan.
|
 |
Abstract
|
|---|
Two rare cases of right atrial pedunculated ball thrombus associated with constrictive pericarditis and systemic lupus erythematosus are reported. Under cardiopulmonary bypass, the large thrombus in each patient was removed with care to avoid pulmonary embolism. Both patients have been doing well postoperatively and warfarin has been administered to prevent a recurrence of intracardiac thrombotic episodes.
|
Introduction
|
|---|
Intracardiac thrombus is commonly observed in the left atrium; a thrombus in the right atrium is considered very rare. However, right atrial thrombi in patients with a permanent pacemaker, intravenous hyperalimentation catheter, or a history of deep vein thrombosis have been reported.1 We treated 2 patients with right atrial ball thrombus associated with chronic constrictive pericarditis in one case and systemic lupus erythematosus in the other.
|
Case Reports
|
|---|
Patient 1
A 54-year-old man was diagnosed as having a right atrial mass by echocardiography and was immediately admitted to the Kinki University Medical Center for surgical treatment. Eight years previously, the patient underwent pericardiectomy through a median sternotomy because of constrictive pericarditis. On admission, warfarin was administered to prevent thrombosis. The prothrombin time and activated partial thromboplastin time were controlled to 35.5 seconds (normal, 10.5 to 14.7 seconds) and 54.9 seconds (normal, 28 to 40 seconds), respectively. Atrial fibrillation was noted on the electrocardiogram and chest radiography revealed pericardial calcification partially adjacent to the diaphragm. The cardiac shadow was moderately enlarged with a cardiothoracic ratio of 0.6. Transthoracic echocardiography demonstrated a heterogeneous mass approximately 2.5 cm in diameter in the enlarged right atrium. Magnetic resonance imaging showed a high-intensity mass in the right atrium but it did not reveal thrombus formation in the pulmonary artery. A ventilation-perfusion scan of the lungs showed no evidence of pulmonary embolism. Based on these evaluations, the right atrial mass was diagnosed as a thrombus and the patient underwent surgical treatment. The heart was exposed through a right lateral thoracotomy. Cardiopulmonary bypass was established with right femoral artery perfusion and superior vena caval and right femoral venous drainage. The inferior vena cava was snared using the caval tape to ensure a bloodless operative field in the right atrium. After a right atriotomy, a 3 x 3 cm pedunculated mass arising from the lateral atrial wall was observed (Figure 1
). The mass was removed en bloc with extensive resection of the right atrial wall (Figure 2). Pathological examination of the mass revealed organized thrombus, negating myxoma, tuberculosis, or malignant diseases. Microscopic inspection of the resected atrial wall attached to the ball thrombus showed myocardial hypertrophy and endocardial fibrosis. The patient has been doing well postoperatively with the administration of warfarin. Thromboembolic episodes have not been observed during 17 months of follow-up examinations.
View larger version (103K):
[in this window]
[in a new window]
|
Figure 2. Photograph of the ball thrombus with the partially resected right atrial wall from patient no. 1.
|
|
Patient 2
A 38-year-old woman who presented with a 19-year history of systemic lupus erythematosus with throm-bocytopenia, ischemic colitis originating from unknown vasculitis, and deep vein thrombosis, was admitted because of a recurrence of colitis. On admission, mild abdominal pain was observed. Laboratory data revealed inflamma-tion; her white blood cell count was 11,100/mm3 and her C-reactive protein level was 14 mg•L–1. Coagulation studies showed a prolonged prothrombin time of 15.8 seconds and a normal activated partial thromboplastin time of 36.4 seconds. Fibrinogen degradation product was slightly elevated to 197 µg•L–1 and positive anti-DNA antibodies were observed in blood examinations. Chest radiography and electrocardiography were normal. Echocardiography 10 days after admission showed normal cardiac function, however, a 2 x 1.5 cm pedunculated right atrial mass originating from the junction of the inferior vena cava was observed. A ventilationperfusion lung scan revealed a diffuse defect of perfusion in the left lung, suggesting pulmonary infarction. The patient underwent surgery through a median sternotomy to remove the atrial mass. Cardiopulmonary bypass was established with aortic cannulation via the ascending aorta and venous cannulation via the superior vena cava. After a right atriotomy, another venous cannula was placed in the inferior vena cava during direct inspection of the right atrial mass. The atrial mass had a peduncle originating from the junction of the inferior vena cava. The mass was easily detached from the atrial wall and removed completely. The patient was weaned off cardiopulmonary bypass with minimal inotropic support. Pathological diagnosis of the resected material was organized thrombus with no evidence of inflammation such as Libman-Sacks endocarditis. The patient was put on warfarin and she has been well postoperatively with no recurrence of embolic or thrombotic episodes during 11 months of follow-up.
|
Discussion
|
|---|
Intracardiac thrombus has been commonly reported in the left atrium or left ventricle in association with mitral stenosis, myocardial infarction, and dilated cardiomyo-pathy. Thrombus in the right atrium is considered rare, although right atrial thrombosis was detected patho-logically by Wartman and Hellerstein2 in 14 of 2000 autopsy cases. To our knowledge, a right atrial pedunculated ball thrombus related to constrictive pericarditis or systemic lupus erythematosus vasculitis has not been reported previously. The classic causes of thrombus formation are stagnation of the bloodstream, injury to the intima, and a disorder of coagulation. The cause of the pedunculated thrombus in patient no. 1 was considered to be a combination of stagnated blood flow related to atrial fibrillation and endocardial changes related to constrictive pericarditis. Based on pathological findings in the endocardium of the stalk, it was strongly suggested that severe inflammation extended to the endocardium of the right atrium from the epicardium, as previously reported.3,6 In patient no. 2, it remains unclear whether thrombus formation was related to lupus. Allen and Jundt4 and Gertner and Leatherman5 studied the relationship between intracardiac thrombosis and antiphospholipid-antibody syndromes with systemic lupus erythematosus. They reported that cardiac manifestations involving thrombus may be partly attributed to antiphospholipid syndrome. Considering the implications of their studies, a relationship between systemic lupus erythematosus and hypercoagulability is strongly suspected in patient no. 2.
It is difficult to distinguish between a thrombus and a tumor such as myxoma when the mass is pedunculated to the atrial wall or atrial septum. Investigations using transesophageal echocardiography and magnetic reso-nance imaging are widely available for the purpose of differential diagnosis. The change in intensity of the magnetic resonance image on administration of gadolinium is helpful and platelet scintigraphy has been reported as effective for diagnosis of intracardiac thrombosis.6,7 The typical appearance of a right atrial thrombus in echocardiography is an immobile layered mass usually attached to the right atrial wall. According to Panidis and colleagues,8 a mobile right atrial thrombus is usually attached to the junction of the inferior vena cava and the lateral right atrial wall.
Patients with a right atrial thrombus carry a potential risk of pulmonary embolism and sudden death due to occlusion of the tricuspid valve. Therefore, immediate surgical treatment is recommended after a diagnosis of atrial thrombosis. During the operation, it is important to prevent perioperative pulmonary embolism. The right femoral vein was used for venous drainage instead of inferior vena caval cannulation in patient no. 1 and inferior vena caval cannulation was carried out while directly inspecting the atrial mass in patient no. 2. Postoperative anticoagu-lation therapy is mandatory to avoid a recurrence of intracardiac thrombosis. Currently, these patients are being followed up regularly by echocardiography.
|
References
|
|---|
-
Minowa T, Nakamura T, Shimanuki T. A case of tumor-like right atrial thrombus. Kyoubu Geka 1996;49:306–9.
-
Wartman WB, Hellerstein HK. The incidence of heart disease in 2,000 consecutive autopsies. Ann Intern Med 1948;28:41–65.[Abstract/Free Full Text]
-
Toda R, Yuda T, Nishida T, Toyohira H, Taira H. Right atrial mural thrombus associated with pericarditis. Ann Thorac Surg 1996;62:1505–6.[Abstract/Free Full Text]
-
Allen BR, Jundt JW. Intracardiac thrombosis and antiphospholipid antibodies: a case report and review of the literature. Southern Med J 1994;87:928–32.[Medline]
-
Gertner E, Leatherman JW. Intracardiac mural thrombus mimicking atrial myxoma in the antiphospholipid syndrome. J Rheumatol 1992;19:1293–8.[Medline]
-
Yoshida M, Kawaraya N, Ota T, Okada M. A case of right atrial thrombus associated with idiopathic pericarditis. J Jpn Assoc Thorac Surg 1994;42:2155–8.
-
Nishimura T, Misawa T, Park YD, Uehara T, Hayashida K, Hayashi M. Visualization of right atrial thrombus associated with constrictive pericarditis by indium-111 oxine platelet imaging. J Nucl Med 1987;28:1344–7.[Abstract/Free Full Text]
-
Panidis IP, Kotler MN, Mintz GS, Ross J. Clinical and echocardiographic features of right atrial masses. Am Heart J 1984;107:745–58.[Medline]
TOP
Abstract
Introduction
