Organized left atrial mural demonstrated by coronary
thrombus angiography
Paul R. Cipriano, M.D. Diana F. Guthaner, M.D. Stanford, Calif.
A variety of uncommon cardiovascular abnormalities have been demonstrated by coronary angiography, including cardiac tumors,‘-” vascular malformations,’ and coronary arterial fistu1as.5-13This communication describes an angiographic abnormality which has a characteristic appearance, was observed during selective coronary angiography in three patients with mitral stenosis, and was due to organized mural thrombus that was adherent to the wall of the left atria1 appendage. Clinical
features
of the patients
Table I summarizes the clinical features of the three patients with mitral stenosis in whom an organized left atria1 mural thrombus was demonstrated by selective coronary arteriography. The patients ranged in age from 67 to 75 years, and had typical symptoms and findings of mitral stenosis on cardiac examination. There was no history of a thromboembolic event in any of the three patients. Patients No. 1 and 3 had atria1 fibrillation. Chest radiographs demonstrated multichambered cardiac enlargement in each patient and mitral valvular calcification in patients No. 1 and 2. Echocardiographic studies were made in patients No. 1 and 2 and revealed findings typical of mitral stenosis, but no evidence of intra-atria1 thrombi. At cardiac catheterization, the mean diastolic pressure gradient across From the Cardiovascular Department of Radiology, Stanford, Call.
Section, Division of Diagnostic Stanford University School
Received
for publication
June
16, 1977.
Accepted
for publication
June
30, 1977.
Reprint requests: Paul S076, Stanford University
166
August,
R. Cipriano, Medical
M.D., Center,
Department Stanford,
1978, Vol. 96, No. 2
Calif.
Radiology, of Medicine,
of Radiology 94305.
the mitral valve ranged from 5 to 15 mm. Hg, and the area of the mitral valve orifice ranged from 0.6 to 0.9 square centimeters. Coronary
angiographic
findings
Selective coronary angiograms of these elderly patients were obtained prior to replacement of the mitral valve to exclude the possibility that their valvular disease might be complicated by coronary artery disease. Coronary arteriography did not demonstrate coronary arterial luminal narrowing in any of the three patients. However, one (patient No. 2) or two (patients No. 1 and 3) small arteries, approximately 1 mm. in diameter, were observed to arise from the circumflex coronary artery, course superiorly, and terminate in a collection of radiographic contrast medium in the left atria1 appendage (Fig. 1, A-C). The collections of radiographic contrast medium were small in patient No. 2 and large in patients No. 1 and 3. These collections were inhomogeneous in density and had irregular shapes and borders. The contrast material appeared to flow from these collections into the lumen of the left atrium in the region of the appendage. Because of the features just described, these vascular channels were considered to represent small coronary arterial-left atria1 fistulas. Anatomic
findings
At operation a single thrombus was found within the left atria1 appendage of each patient. These thrombi ranged from less than 1 cm. to 5 cm. in length and were adherent to the wall of the left atria1 appendage. In each patient the thrombus was removed and the mitral valve was replaced. Microscopic examination of the atria1
COO2-8703/78/0296-0166$00.40/O
0 1978
The
C. V. Mosby
Co.
LA mural
thrombus
by nngiography
Fig. 1, A through D. A-C, Selective left coronary artery angiograms demonstrating coronary artery fistulas which terminate in a large or small collection of radiographic contrast medium in the left atria1 appendage. A. Patient No. 3, right anterior oblique view, two atria1 coronary artery fistulas (arrows). B, Patient No. 2, left auterior oblique view, one atria1 coronary artery fistula (small arrow); the collection of radiographic contrast medium is small (large arrow). C, Patient No. 1, left anterior oblique view, two atria1 coronary artery fistulas (arrows ). D, Histologic section showing organizing thrombus that was removed from the left atria1 appendage of patient. No. 2 (Hematoxylin-eosin stain; o&inal magnification x 6.3).
thrombi showed various stages of organiziation (Fig. 1D). The organizing areas of the thrombi had sinuses which contained red blood cells and the organized areas of the thrombi were dense with fibrous tissue. Arterioles or venules were not present within the thrombus, but a few, small vascular channels were observed that were composed only of a single layer of endothelial cells. There was no correlation between the size of the thrombus (Table I) and the size of the collection of radiographic contrast material observed during coronary angiography (Fig. 1,
A-C).
American
Heart
Journal
Discussion
Non-atherosclerotic cardiovascular abnormalities that are demonstrated by coronary angiography, such as cardiac tumors, vascular malformations, and large coronary artery fistulas are uncommon but frequently have characteristic angiographic appearances. These features differ from those observed in this study. To our knowledge, arteriographic abnormalities due to cardiac tumors have been reported only in three cases: a myxoma,’ a hamartoma,’ and a hemangioma.” A small amount of radiographic contrast material was observed in a left
167
Cipriano
and
Guthaner
I. Patients with organized left atria1 mural thrombus demonstrated by selective coronary angiography
Table
Patient No.
Age/sex
Cardiac symptoms
Murmurs
1
67M
DOE and palpitations
MS MR
2
69F
3
75F
DOE, PND, palpitations DOE, orthopnea palpitations
MS MR MS MR TR
ECG AF LAD lo AV block PVCs, LAE AF, IRBBB
Chest radiograph IPE, RVE, LAE, LVE, MV-Ca PVH, RVE, LAE, MV-Ca PVH, RVE, LAE, LVE
Echocardiogram
Mitral valve gradient (mm. Hg)/ orifice (cm.7
Length of thrombus
LAE MS
15/0.6
5 cm.
LAE MS
WO.6
5 cm.
510.9
< 1 cm.
Abbreviations and symbols: - = data not available; AF = atria1 filbrillation; AV = atrioventricular; DOE = dyspnea on exertion; ECG diogram; IPE = interstitial pulmonary edema; IRBBB = incomplete right bundle branch block; LAD = left axis deviation; LAE enlargement; LVE = left ventricular enlargement; MR = mitral regurgitation; MS = mitral stenosis; MV-Ca = mitral valve PND = paroxysmal nocturnal dyspnea; PVCs = premature ventricular contractions; PVH = pulmonary venous hypertension; RVE = ular enlargement; TR = tricuspid regurgitation.
atria1 myxoma, presumably within the tumor, during selective right coronary angiography.’ A hamartoma2 and a hemangioma” have been demonstrated in children by ascending thoracic aortography. Both of these tumors were located at the apex of the heart. Both tumors were supplied by enlarged, tortuous branches of the left anterior descending coronary artery; these branches terminated in a dense mass of vessels that emptied slowly into the coronary venous system but did not communicate directly with the left ventricular chamber. Among coronary vascular malformations, drainage of all left coronary arterial flow into the left ventricle through thebesian veins4 has been recognized by means of coronary angiography. Coronary angiograms demonstrated multiple, tortuous epicardial arteries terminating in an intense myocardial collection of contrast material which drained directly into the left ventricular chamber without filling any coronary veins or the coronary sinus. Large coronary arterial fistulas may be composed of a single vessel or many vessels and may involve one or more coronary arteries.5-1” Coronary arterial fistulas communicate with the right heart more often than with the left heart or with the pulmonary circulation.“-” The small coronary-left atria1 fistulas observed in this study appeared to empty directly into the left atrium without having demonstrable venous drainage. These fistulas were small and could not have produced congestive heart failure or myocardial
168
= electrocar= left atria1 calcification; right ventric-
ischemia due to shunting of blood from the coronary arteries to the left atrium. An angiographic abnormality similar to the one which we have observed has been demonstrated at operation to be due to a ventriculaF4 and to an atrial15 mural thrombus. The small vessels that we observed in the excised portions of the atria1 thrombi were too small to account for the collections of radiographic contrast material that were observed during coronary angiography. Therefore, we presume that these collections were present within vascular channels located either in the most basal portions of the thrombi or in the immediately subjacent areas of the left atrium. Microscopic studies have demonstrated that cardiac mural thrombi may be invaded by new vessels as they become organized.‘” Ii Thus, it is possible that these ingrowing vessels form dilated vascular channels in an effort to resorb the thrombus. The following conclusions can be drawn from the data reviewed above: (1) small arterial fistulas that terminate at the site of an adherent, organized mural thrombus in the left atria1 appendage may be observed incidentally during selective coronary angiography in patients with mitral stenosis; (2) the angiographic features of this vascular abnormality can be distinguished from those of cardiac tumors, vascular malformations, and coronary artery fistulas that are not associated with organized thrombus; (3) the vascular abnormality demonstrated by coronary angiography may be the only indication of the
August,
1978,
Vol.
96, No.
2
LA mural
presence of a left atria1 thrombus; (4) this abnormality may be present in thrombi that are not revealed by echocardiography and are not manifest clinically by systemic emboli; and (5) the size of the collection of radiographic contrast material in the left atria1 appendage is not proportional to the size of the thrombus. Summary
5.
6.
7.
8.
Small coronary artery fistulas terminating at the site of adherent, organized mural thrombi in the left atria1 appendage were observed during selective coronary angiography in patients with mitral stenosis. The angiographic features of this abnormality can be distinguished from those of cardiac tumors, vascular malformations, and coronary artery fistulas that are not associated with organized thrombus. This coronary angiographic abnormality may indicate the presence of left atria1 thrombus that is qot revealed by echocardiography and is not manifest clinically by systemic emboli. The size of the collection of radiographic contrast material in the left atrium is not proportional to the size of the thrombus.
9.
10.
11.
12.
13.
14.
REFERENCES 1.
2.
3.
4.
Marshall, W. H., Steiner, R. M., and Wexler, L.: “Tumor vascularity” in left atria1 myxoma demonstrated by selective coronary arteriography, Radiology 93:815, 1969. Franciosi, R. A., Gay, R. M., and Ah-Tye, P.: Vascular hamartoma of the heart in a child, AM. HEART J. 79:676, 1970. Sulayman, R., and Cassels, D. E.: Myocardial coronary hemangiomatous tumors in children, Chest 66:113, 1975. Kinard, S. A.: Hypoplasia of the coronary sinus with coronary venous drainage into the left ventricle by way of the Thebesian system, Chest 66:384, 1975.
American
Heart
Journal
15.
16.
17.
th.rombus
by !zngiography
Gasul, B. M., Arcilla, R. A., Fell, E. H., et al.: Congenital coronary arteriovenous fistula. Clinical, phonocardiographic angiocardiographic and hemodynamic studies in five patients, Pediatrics (Suppl.):531-560, March, 1960. Neufield, H. N., Lester, R. G., Adams, P., et al.: Congenital communication of a coronary artery with a cardiac chamber or the pulmonary trunk i”Coronary artery fistula”). Circulation 24:171, 1961. Upshaw, C. B.: Congenital coronary arteriovenous f%stula. Report of a case with an analysis ot seventy-three reported cases, AM. HEART J. 63:399. 196s. Dedichen, H., Skalleberg, L., and Chappeien, C.: Congenital coronary artery fistula, Thorax 21: 121, 1966. Gobel, F. L., Anderson, C. F., Baltaxe, H. A., et al.: Shunts between the coronary and pulmonary arteries with normal origin of the coronary arteries, Am. J. Cardiol. 25:655, 1970. Eie, H., and Hillestad, L.: Arterio-venous fistulae of the coronary arteries. A report of six cases, Stand. J. Thorac. Cardiovasc. Surg. 5:34, 1971. Reddy, K., Gupta, M., and Hamby, R. 1.: Multiple coronary arteriosystemic fistulas. Am. d. C’srdiol. 33:304, 1974. Silverman, J. F., Obrez, I., and Kriss. J. P.: Coronary artery fistula: Diagnosis and evaluation by selective contrast and radioisotopic coronary arteriography, J. Can. Assoc. Radiol. 25:310, 1974. Herscheman, A., Natarajan, N., and Reddy, R.: Multiple fistulas between the coronary arteries and the left ventricle, Radiology 122:302, 1977. Grollman, J. H., Hoffman, R. B., Price. J. E., et al.: Abnormal vascularity in left ventricular mural thrombus demonstrated by selective coronary arteriography, Radiology 113:591, 1974. Standen, J. R.: “Tumor vascularity” in left atrial thrombus demonstrated by selective coronary arteriography, Radiology 116:549, 1975. Mitchell, J. R. A., and Schwartz, C. ,J.: Arterial disease, Oxford, 1965, Blackwell Scientific Publications, pp. 151154. Farrer-Brown, G.: Normal and diseased vascular pattern of myocardium of human heart II. Pattern seen with fibrosis of the left ventricular free wall. Br. Heart. J. 30537. 1968.
169
thrombus angiography
Paul R. Cipriano, M.D. Diana F. Guthaner, M.D. Stanford, Calif.
A variety of uncommon cardiovascular abnormalities have been demonstrated by coronary angiography, including cardiac tumors,‘-” vascular malformations,’ and coronary arterial fistu1as.5-13This communication describes an angiographic abnormality which has a characteristic appearance, was observed during selective coronary angiography in three patients with mitral stenosis, and was due to organized mural thrombus that was adherent to the wall of the left atria1 appendage. Clinical
features
of the patients
Table I summarizes the clinical features of the three patients with mitral stenosis in whom an organized left atria1 mural thrombus was demonstrated by selective coronary arteriography. The patients ranged in age from 67 to 75 years, and had typical symptoms and findings of mitral stenosis on cardiac examination. There was no history of a thromboembolic event in any of the three patients. Patients No. 1 and 3 had atria1 fibrillation. Chest radiographs demonstrated multichambered cardiac enlargement in each patient and mitral valvular calcification in patients No. 1 and 2. Echocardiographic studies were made in patients No. 1 and 2 and revealed findings typical of mitral stenosis, but no evidence of intra-atria1 thrombi. At cardiac catheterization, the mean diastolic pressure gradient across From the Cardiovascular Department of Radiology, Stanford, Call.
Section, Division of Diagnostic Stanford University School
Received
for publication
June
16, 1977.
Accepted
for publication
June
30, 1977.
Reprint requests: Paul S076, Stanford University
166
August,
R. Cipriano, Medical
M.D., Center,
Department Stanford,
1978, Vol. 96, No. 2
Calif.
Radiology, of Medicine,
of Radiology 94305.
the mitral valve ranged from 5 to 15 mm. Hg, and the area of the mitral valve orifice ranged from 0.6 to 0.9 square centimeters. Coronary
angiographic
findings
Selective coronary angiograms of these elderly patients were obtained prior to replacement of the mitral valve to exclude the possibility that their valvular disease might be complicated by coronary artery disease. Coronary arteriography did not demonstrate coronary arterial luminal narrowing in any of the three patients. However, one (patient No. 2) or two (patients No. 1 and 3) small arteries, approximately 1 mm. in diameter, were observed to arise from the circumflex coronary artery, course superiorly, and terminate in a collection of radiographic contrast medium in the left atria1 appendage (Fig. 1, A-C). The collections of radiographic contrast medium were small in patient No. 2 and large in patients No. 1 and 3. These collections were inhomogeneous in density and had irregular shapes and borders. The contrast material appeared to flow from these collections into the lumen of the left atrium in the region of the appendage. Because of the features just described, these vascular channels were considered to represent small coronary arterial-left atria1 fistulas. Anatomic
findings
At operation a single thrombus was found within the left atria1 appendage of each patient. These thrombi ranged from less than 1 cm. to 5 cm. in length and were adherent to the wall of the left atria1 appendage. In each patient the thrombus was removed and the mitral valve was replaced. Microscopic examination of the atria1
COO2-8703/78/0296-0166$00.40/O
0 1978
The
C. V. Mosby
Co.
LA mural
thrombus
by nngiography
Fig. 1, A through D. A-C, Selective left coronary artery angiograms demonstrating coronary artery fistulas which terminate in a large or small collection of radiographic contrast medium in the left atria1 appendage. A. Patient No. 3, right anterior oblique view, two atria1 coronary artery fistulas (arrows). B, Patient No. 2, left auterior oblique view, one atria1 coronary artery fistula (small arrow); the collection of radiographic contrast medium is small (large arrow). C, Patient No. 1, left anterior oblique view, two atria1 coronary artery fistulas (arrows ). D, Histologic section showing organizing thrombus that was removed from the left atria1 appendage of patient. No. 2 (Hematoxylin-eosin stain; o&inal magnification x 6.3).
thrombi showed various stages of organiziation (Fig. 1D). The organizing areas of the thrombi had sinuses which contained red blood cells and the organized areas of the thrombi were dense with fibrous tissue. Arterioles or venules were not present within the thrombus, but a few, small vascular channels were observed that were composed only of a single layer of endothelial cells. There was no correlation between the size of the thrombus (Table I) and the size of the collection of radiographic contrast material observed during coronary angiography (Fig. 1,
A-C).
American
Heart
Journal
Discussion
Non-atherosclerotic cardiovascular abnormalities that are demonstrated by coronary angiography, such as cardiac tumors, vascular malformations, and large coronary artery fistulas are uncommon but frequently have characteristic angiographic appearances. These features differ from those observed in this study. To our knowledge, arteriographic abnormalities due to cardiac tumors have been reported only in three cases: a myxoma,’ a hamartoma,’ and a hemangioma.” A small amount of radiographic contrast material was observed in a left
167
Cipriano
and
Guthaner
I. Patients with organized left atria1 mural thrombus demonstrated by selective coronary angiography
Table
Patient No.
Age/sex
Cardiac symptoms
Murmurs
1
67M
DOE and palpitations
MS MR
2
69F
3
75F
DOE, PND, palpitations DOE, orthopnea palpitations
MS MR MS MR TR
ECG AF LAD lo AV block PVCs, LAE AF, IRBBB
Chest radiograph IPE, RVE, LAE, LVE, MV-Ca PVH, RVE, LAE, MV-Ca PVH, RVE, LAE, LVE
Echocardiogram
Mitral valve gradient (mm. Hg)/ orifice (cm.7
Length of thrombus
LAE MS
15/0.6
5 cm.
LAE MS
WO.6
5 cm.
510.9
< 1 cm.
Abbreviations and symbols: - = data not available; AF = atria1 filbrillation; AV = atrioventricular; DOE = dyspnea on exertion; ECG diogram; IPE = interstitial pulmonary edema; IRBBB = incomplete right bundle branch block; LAD = left axis deviation; LAE enlargement; LVE = left ventricular enlargement; MR = mitral regurgitation; MS = mitral stenosis; MV-Ca = mitral valve PND = paroxysmal nocturnal dyspnea; PVCs = premature ventricular contractions; PVH = pulmonary venous hypertension; RVE = ular enlargement; TR = tricuspid regurgitation.
atria1 myxoma, presumably within the tumor, during selective right coronary angiography.’ A hamartoma2 and a hemangioma” have been demonstrated in children by ascending thoracic aortography. Both of these tumors were located at the apex of the heart. Both tumors were supplied by enlarged, tortuous branches of the left anterior descending coronary artery; these branches terminated in a dense mass of vessels that emptied slowly into the coronary venous system but did not communicate directly with the left ventricular chamber. Among coronary vascular malformations, drainage of all left coronary arterial flow into the left ventricle through thebesian veins4 has been recognized by means of coronary angiography. Coronary angiograms demonstrated multiple, tortuous epicardial arteries terminating in an intense myocardial collection of contrast material which drained directly into the left ventricular chamber without filling any coronary veins or the coronary sinus. Large coronary arterial fistulas may be composed of a single vessel or many vessels and may involve one or more coronary arteries.5-1” Coronary arterial fistulas communicate with the right heart more often than with the left heart or with the pulmonary circulation.“-” The small coronary-left atria1 fistulas observed in this study appeared to empty directly into the left atrium without having demonstrable venous drainage. These fistulas were small and could not have produced congestive heart failure or myocardial
168
= electrocar= left atria1 calcification; right ventric-
ischemia due to shunting of blood from the coronary arteries to the left atrium. An angiographic abnormality similar to the one which we have observed has been demonstrated at operation to be due to a ventriculaF4 and to an atrial15 mural thrombus. The small vessels that we observed in the excised portions of the atria1 thrombi were too small to account for the collections of radiographic contrast material that were observed during coronary angiography. Therefore, we presume that these collections were present within vascular channels located either in the most basal portions of the thrombi or in the immediately subjacent areas of the left atrium. Microscopic studies have demonstrated that cardiac mural thrombi may be invaded by new vessels as they become organized.‘” Ii Thus, it is possible that these ingrowing vessels form dilated vascular channels in an effort to resorb the thrombus. The following conclusions can be drawn from the data reviewed above: (1) small arterial fistulas that terminate at the site of an adherent, organized mural thrombus in the left atria1 appendage may be observed incidentally during selective coronary angiography in patients with mitral stenosis; (2) the angiographic features of this vascular abnormality can be distinguished from those of cardiac tumors, vascular malformations, and coronary artery fistulas that are not associated with organized thrombus; (3) the vascular abnormality demonstrated by coronary angiography may be the only indication of the
August,
1978,
Vol.
96, No.
2
LA mural
presence of a left atria1 thrombus; (4) this abnormality may be present in thrombi that are not revealed by echocardiography and are not manifest clinically by systemic emboli; and (5) the size of the collection of radiographic contrast material in the left atria1 appendage is not proportional to the size of the thrombus. Summary
5.
6.
7.
8.
Small coronary artery fistulas terminating at the site of adherent, organized mural thrombi in the left atria1 appendage were observed during selective coronary angiography in patients with mitral stenosis. The angiographic features of this abnormality can be distinguished from those of cardiac tumors, vascular malformations, and coronary artery fistulas that are not associated with organized thrombus. This coronary angiographic abnormality may indicate the presence of left atria1 thrombus that is qot revealed by echocardiography and is not manifest clinically by systemic emboli. The size of the collection of radiographic contrast material in the left atrium is not proportional to the size of the thrombus.
9.
10.
11.
12.
13.
14.
REFERENCES 1.
2.
3.
4.
Marshall, W. H., Steiner, R. M., and Wexler, L.: “Tumor vascularity” in left atria1 myxoma demonstrated by selective coronary arteriography, Radiology 93:815, 1969. Franciosi, R. A., Gay, R. M., and Ah-Tye, P.: Vascular hamartoma of the heart in a child, AM. HEART J. 79:676, 1970. Sulayman, R., and Cassels, D. E.: Myocardial coronary hemangiomatous tumors in children, Chest 66:113, 1975. Kinard, S. A.: Hypoplasia of the coronary sinus with coronary venous drainage into the left ventricle by way of the Thebesian system, Chest 66:384, 1975.
American
Heart
Journal
15.
16.
17.
th.rombus
by !zngiography
Gasul, B. M., Arcilla, R. A., Fell, E. H., et al.: Congenital coronary arteriovenous fistula. Clinical, phonocardiographic angiocardiographic and hemodynamic studies in five patients, Pediatrics (Suppl.):531-560, March, 1960. Neufield, H. N., Lester, R. G., Adams, P., et al.: Congenital communication of a coronary artery with a cardiac chamber or the pulmonary trunk i”Coronary artery fistula”). Circulation 24:171, 1961. Upshaw, C. B.: Congenital coronary arteriovenous f%stula. Report of a case with an analysis ot seventy-three reported cases, AM. HEART J. 63:399. 196s. Dedichen, H., Skalleberg, L., and Chappeien, C.: Congenital coronary artery fistula, Thorax 21: 121, 1966. Gobel, F. L., Anderson, C. F., Baltaxe, H. A., et al.: Shunts between the coronary and pulmonary arteries with normal origin of the coronary arteries, Am. J. Cardiol. 25:655, 1970. Eie, H., and Hillestad, L.: Arterio-venous fistulae of the coronary arteries. A report of six cases, Stand. J. Thorac. Cardiovasc. Surg. 5:34, 1971. Reddy, K., Gupta, M., and Hamby, R. 1.: Multiple coronary arteriosystemic fistulas. Am. d. C’srdiol. 33:304, 1974. Silverman, J. F., Obrez, I., and Kriss. J. P.: Coronary artery fistula: Diagnosis and evaluation by selective contrast and radioisotopic coronary arteriography, J. Can. Assoc. Radiol. 25:310, 1974. Herscheman, A., Natarajan, N., and Reddy, R.: Multiple fistulas between the coronary arteries and the left ventricle, Radiology 122:302, 1977. Grollman, J. H., Hoffman, R. B., Price. J. E., et al.: Abnormal vascularity in left ventricular mural thrombus demonstrated by selective coronary arteriography, Radiology 113:591, 1974. Standen, J. R.: “Tumor vascularity” in left atrial thrombus demonstrated by selective coronary arteriography, Radiology 116:549, 1975. Mitchell, J. R. A., and Schwartz, C. ,J.: Arterial disease, Oxford, 1965, Blackwell Scientific Publications, pp. 151154. Farrer-Brown, G.: Normal and diseased vascular pattern of myocardium of human heart II. Pattern seen with fibrosis of the left ventricular free wall. Br. Heart. J. 30537. 1968.
169
