Cardiovascular Pathology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Cardiovascular Pathology
Images in Cardiovascular Pathology
Right atrial thrombus arising from the junction of the right atrium and the inferior vena cava Rajanshu Verma a,⁎, Emily R. Duncanson b, Ambareesh Bajpai c, Nedaa Skeik d, Salima Shafi c a
United Hospitalist Service, United Hospital, Allina Health, St. Paul, MN Jesse E Edwards Registry of Cardiovascular Disease, John Nasseff Heart Hospital, St. Paul, MN United Heart & Vascular Clinic, Nasseff Specialty Center, St. Paul, MN d Vascular Medicine, Minneapolis Heart Institute—Vascular & Endovascular Services, Minneapolis, MN b c
a r t i c l e
i n f o
Article history: Received 14 March 2014 Received in revised form 2 April 2014 Accepted 2 April 2014 Available online xxxx Keywords: Right atrial thrombus Cardiac imaging Cardiac thrombus Sudden death Transesophageal echocardiography
a b s t r a c t Background: Cardiac tumors are a rare cause of recurrent syncope which are detected on echocardiography, computed tomographic scan, and/or magnetic resonance imaging. We present echocardiographic, anatomic, and histopathologic images of a cardiac tumor arising from the junction of the right atrium and the inferior vena cava in a young lady. Methods: Transthoracic echocardiography, transesophageal echocardiography, postmortem examination (autopsy), and histopathology. Results: Transesophageal echocardiogram showed a 7×3-cm mobile multilobulated right atrial mass arising from the right atrial wall near the inferior vena cava. The patient was admitted to hospital to undergo cardiac surgery; however, unfortunately, she went in to cardiorespiratory arrest on the eve before surgery. Autopsy showed embolized mass obstructing the main pulmonary trunk, and pathology revealed an old organizing thrombus. Conclusions: Cardiac thrombi can mimic appearances of a myxoma on echocardiogram. Delay in thrombus removal surgery can result in increased mortality as seen in our case. © 2014 Elsevier Inc. All rights reserved.
A 42-year-old Hispanic lady presented to her primary care physician with symptoms of recurrent syncope. Her medical history included impaired fasting glucose, migraine, stress urinary incontinence, insomnia, obesity (body mass index 54 kg/m 2), depression, and obsessive–compulsive disorder. On exam, no cardiac murmur, pedal edema, hepatomegaly, or ascites was found. When a 24-h Holter monitor result came back normal, an echocardiogram was ordered which showed presence of a mobile myxoma-like mass in the right atrium which crossed the tricuspid valve in diastole. Transesophageal echocardiogram confirmed the presence of a 7×3-cm mobile multilobulated right atrial mass arising from the right atrial wall near the inferior vena cava (Fig. 1; Videos 1– 3). Left ventricular ejection fraction was 65%. She had no personal or family history of clotting disorders. She did not have any history of cancer; connective tissue disorders; exposure to chemotherapeutic drugs; or recent or remote instrumentation or surgery on her neck, chest, or abdomen. Six months prior to presentation, she had used hormonal contraceptives for metrorrhagia; however, she had quit
We have no funding sources to declare. Disclosures: none. ⁎ Corresponding author. United Hospitalist Service, 333 N Smith Ave, Suite 4136, St. Paul, MN 55102. Tel.: +1 651 241 8000; fax: +1 651 241 8451. E-mail address: [email protected] (R. Verma).
taking them for the last 2 months. The patient was admitted to hospital with plans to undergo cardiac surgery for removal of the right atrial mass. Her electrocardiogram showed normal sinus rhythm. Her international normalized ratio was normal, and she was started on subcutaneous heparin for deep vein thrombosis prophylaxis. On the day before surgery, the patient went in to cardiorespiratory arrest, becoming unresponsive with bradycardia and cyanosis. Despite prolonged resuscitative efforts with administration of epinephrine, vasopressin, atropine, bicarbonate, calcium, 5% dextrose, and endotracheal intubation, she could not be revived. The cause of death was presumed to be circulatory collapse from tumor embolus following detachment of the right atrial mass from its stalk. Autopsy showed an 8×2.5×2-cm mass with point of adherence at the junction of the inferior vena cava and the right atrium (Figs. 2–4) that had embolized to the right ventricular outflow tract and pulmonary artery. The rest of the autopsy was negative. Histopathologic examination of the mass revealed an old organizing thrombus in various stages of organization consisting of fibrin and degenerating inflammatory cells. No myxoma cells were seen (Fig. 5). This case describes how echocardiographic features of a thrombus can mimic those of a myxoma, creating a diagnostic dilemma. Differentiating thrombus from myxoma on imaging can be difficult [1]. Characteristics of a thrombus depend on its age, hemosiderin content, and presence of calcification [2]. In terms of treatment of intracardiac thrombus, cardiac surgery is the preferred treatment over
http://dx.doi.org/10.1016/j.carpath.2014.04.002 1054-8807/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Verma R, et al, Right atrial thrombus arising from the junction of the right atrium and the inferior vena cava, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.04.002
2
R. Verma et al. / Cardiovascular Pathology xxx (2014) xxx–xxx
Fig. 1. Transesophageal echocardiographic view showing extent of thrombus. Fig. 4. Figure showing attachment of thrombus stalk at the junction of the inferior vena cava and the right atrium.
Fig. 2. Thromboembolus in right ventricle as marked by white arrow.
Fig. 5. Histopathology showing organizing thrombus.
fibrinolysis. Delay in thrombus removal surgery may result in increased mortality as in our case [3]. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.carpath.2014.04.002. Acknowledgments None. References
Fig. 3. Thromboembolus traversing pulmonary artery.
[1] Pandit A, Panse PM, Aryal A, Gruden JF, Gotway M. A new intracavitary lesion at echocardiography and MR: a case of mistaken identity. Int J Cardiovasc Imaging 2013;29:1203–5. [2] Attili AK, Gebker R, Cascade PN. Radiological reasoning: right atrial mass. AJR Am J Roentgenol 2007;188:S26–30. [3] Darwazah AK, Eida M, Batrawy M. Myxoma at junction of inferior vena cava and right atrium: surgical excision. Tex Heart Inst J 2011;38:591–3.
Please cite this article as: Verma R, et al, Right atrial thrombus arising from the junction of the right atrium and the inferior vena cava, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.04.002
Contents lists available at ScienceDirect
Cardiovascular Pathology
Images in Cardiovascular Pathology
Right atrial thrombus arising from the junction of the right atrium and the inferior vena cava Rajanshu Verma a,⁎, Emily R. Duncanson b, Ambareesh Bajpai c, Nedaa Skeik d, Salima Shafi c a
United Hospitalist Service, United Hospital, Allina Health, St. Paul, MN Jesse E Edwards Registry of Cardiovascular Disease, John Nasseff Heart Hospital, St. Paul, MN United Heart & Vascular Clinic, Nasseff Specialty Center, St. Paul, MN d Vascular Medicine, Minneapolis Heart Institute—Vascular & Endovascular Services, Minneapolis, MN b c
a r t i c l e
i n f o
Article history: Received 14 March 2014 Received in revised form 2 April 2014 Accepted 2 April 2014 Available online xxxx Keywords: Right atrial thrombus Cardiac imaging Cardiac thrombus Sudden death Transesophageal echocardiography
a b s t r a c t Background: Cardiac tumors are a rare cause of recurrent syncope which are detected on echocardiography, computed tomographic scan, and/or magnetic resonance imaging. We present echocardiographic, anatomic, and histopathologic images of a cardiac tumor arising from the junction of the right atrium and the inferior vena cava in a young lady. Methods: Transthoracic echocardiography, transesophageal echocardiography, postmortem examination (autopsy), and histopathology. Results: Transesophageal echocardiogram showed a 7×3-cm mobile multilobulated right atrial mass arising from the right atrial wall near the inferior vena cava. The patient was admitted to hospital to undergo cardiac surgery; however, unfortunately, she went in to cardiorespiratory arrest on the eve before surgery. Autopsy showed embolized mass obstructing the main pulmonary trunk, and pathology revealed an old organizing thrombus. Conclusions: Cardiac thrombi can mimic appearances of a myxoma on echocardiogram. Delay in thrombus removal surgery can result in increased mortality as seen in our case. © 2014 Elsevier Inc. All rights reserved.
A 42-year-old Hispanic lady presented to her primary care physician with symptoms of recurrent syncope. Her medical history included impaired fasting glucose, migraine, stress urinary incontinence, insomnia, obesity (body mass index 54 kg/m 2), depression, and obsessive–compulsive disorder. On exam, no cardiac murmur, pedal edema, hepatomegaly, or ascites was found. When a 24-h Holter monitor result came back normal, an echocardiogram was ordered which showed presence of a mobile myxoma-like mass in the right atrium which crossed the tricuspid valve in diastole. Transesophageal echocardiogram confirmed the presence of a 7×3-cm mobile multilobulated right atrial mass arising from the right atrial wall near the inferior vena cava (Fig. 1; Videos 1– 3). Left ventricular ejection fraction was 65%. She had no personal or family history of clotting disorders. She did not have any history of cancer; connective tissue disorders; exposure to chemotherapeutic drugs; or recent or remote instrumentation or surgery on her neck, chest, or abdomen. Six months prior to presentation, she had used hormonal contraceptives for metrorrhagia; however, she had quit
We have no funding sources to declare. Disclosures: none. ⁎ Corresponding author. United Hospitalist Service, 333 N Smith Ave, Suite 4136, St. Paul, MN 55102. Tel.: +1 651 241 8000; fax: +1 651 241 8451. E-mail address: [email protected] (R. Verma).
taking them for the last 2 months. The patient was admitted to hospital with plans to undergo cardiac surgery for removal of the right atrial mass. Her electrocardiogram showed normal sinus rhythm. Her international normalized ratio was normal, and she was started on subcutaneous heparin for deep vein thrombosis prophylaxis. On the day before surgery, the patient went in to cardiorespiratory arrest, becoming unresponsive with bradycardia and cyanosis. Despite prolonged resuscitative efforts with administration of epinephrine, vasopressin, atropine, bicarbonate, calcium, 5% dextrose, and endotracheal intubation, she could not be revived. The cause of death was presumed to be circulatory collapse from tumor embolus following detachment of the right atrial mass from its stalk. Autopsy showed an 8×2.5×2-cm mass with point of adherence at the junction of the inferior vena cava and the right atrium (Figs. 2–4) that had embolized to the right ventricular outflow tract and pulmonary artery. The rest of the autopsy was negative. Histopathologic examination of the mass revealed an old organizing thrombus in various stages of organization consisting of fibrin and degenerating inflammatory cells. No myxoma cells were seen (Fig. 5). This case describes how echocardiographic features of a thrombus can mimic those of a myxoma, creating a diagnostic dilemma. Differentiating thrombus from myxoma on imaging can be difficult [1]. Characteristics of a thrombus depend on its age, hemosiderin content, and presence of calcification [2]. In terms of treatment of intracardiac thrombus, cardiac surgery is the preferred treatment over
http://dx.doi.org/10.1016/j.carpath.2014.04.002 1054-8807/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Verma R, et al, Right atrial thrombus arising from the junction of the right atrium and the inferior vena cava, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.04.002
2
R. Verma et al. / Cardiovascular Pathology xxx (2014) xxx–xxx
Fig. 1. Transesophageal echocardiographic view showing extent of thrombus. Fig. 4. Figure showing attachment of thrombus stalk at the junction of the inferior vena cava and the right atrium.
Fig. 2. Thromboembolus in right ventricle as marked by white arrow.
Fig. 5. Histopathology showing organizing thrombus.
fibrinolysis. Delay in thrombus removal surgery may result in increased mortality as in our case [3]. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.carpath.2014.04.002. Acknowledgments None. References
Fig. 3. Thromboembolus traversing pulmonary artery.
[1] Pandit A, Panse PM, Aryal A, Gruden JF, Gotway M. A new intracavitary lesion at echocardiography and MR: a case of mistaken identity. Int J Cardiovasc Imaging 2013;29:1203–5. [2] Attili AK, Gebker R, Cascade PN. Radiological reasoning: right atrial mass. AJR Am J Roentgenol 2007;188:S26–30. [3] Darwazah AK, Eida M, Batrawy M. Myxoma at junction of inferior vena cava and right atrium: surgical excision. Tex Heart Inst J 2011;38:591–3.
Please cite this article as: Verma R, et al, Right atrial thrombus arising from the junction of the right atrium and the inferior vena cava, Cardiovasc Pathol (2014), http://dx.doi.org/10.1016/j.carpath.2014.04.002
