256 echocardiography of atrioventricular septal defect. J Am Coil Cardiol 1991;18:537-545. 3 Sreeram N, Stumper OFW, Kaulitz R, Hess J, Roelandt JRTC, Sutherland GR. Comparative value of transthoracic and transesophageal echocardiography in the assessment of congenital abnormalities of the atrioventricular junction. J Am Coil Cardiol 1990;16:1205-1214.
4 Clapp SJ, Perry BL, Farooki ZQ et al. Surgical and medical results of complete atrioventricular canal: a ten year review. Am J Cardiol 1987;59:454-458. 5 Silverman NH, Zuberbuhler JR, Anderson RH, Atrioventricular septal defects: cross-sectional echocardiographic and morphologic comparisons. Int J Cardiol 1986;13:309331.
International Journal of Cardiology, 37 (1992) 2.56-258 0 1992 Elsevier Scientific Publishers Ltd. All rights reserved 0167-5273/92/$05.00
CARD10 15562
Right atria1 thrombus in constrictive pericarditis Kim A. Priestley, John Wallwork and Peter M. Schofield Departments of Cardiology and Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
(Received 10 June 1992; accepted 10 June 1992)
We describe right atria1 thrombus complicated by tricuspid valve obstruction in a patient with constrictive pericarditis. This report highlights the role of surgical thrombectomy, and the investigation of constrictive pericarditis to exclude intra-cardiac thrombus. Key words: Right atria1 thrombus; Constrictive pericarditis
Introduction
Case Report
Right atria1 thrombus is uncommon and usually found in patients with right-sided cardiac abnormalities or foreign bodies [1,2]. Since pulmonary embolism and right heart failure are complications of right atria1 thrombus surgical thrombectomy may be advised. We report a case of constrictive pericarditis, right atria1 thrombus and haemodynamic collapse due to tricuspid valve obstruction during surgery.
A 43-yr-old man was admitted with increasing breathlessness and fatigue 4 months after pericarditis complicated by a moderate pericardial effusion which was managed conservatively. His past medical history included renal failure requiring continuous ambulatory peritoneal dialysis for the last 11 months. Physical examination revealed atria1 fibrillation at 90 beats/min and hypotension, blood pressure 80/60 mmHg with 20 mm of paradox. The jugular venous pressure was raised and he had abdominal distension and peripheral oedema. Echocardiography showed bright pericardial echoes but no pericardial fluid and cardiac constriction was suspected. Haemodynamic studies demonstrated near equalisation of end diastolic pressures in all 4
Correspondence to: Dr. K. Priestley, Dept. of Invasive Cardiol-
ogy, Royal Brompton National Heart & Lung Hospital, Sydney Street, London SW3 6NP, U.K. Tel. 071 351 8625. Fax 071 351 8614.
Fig. 1. Contrast-enhanced computed tomographic scan of mediastinum. Left: transverse section showing a filling defect within the right atrium (arrows). Right: transverse section showing pericardial thickening (arrows).
cardiac chambers and a “dip and plateau” pattern was seen in both ventricles. Coronary angiography was normal. Contrast computed tomography confirmed pericardial thickening and revealed a mass 4 cm in diameter within the right atrium (Fig. 1). Surgery was performed via a median sternotomy. During mobilisation of the heart the patient suffered haemodynamic collapse characteristic of tricuspid valve obstruction with an abrupt rise in right atria1 pressure and a precipitous fall in systemic arterial pressure. The patient responded rapidly when cardiopulmonary bypass was instituted followed by right atriotomy and removal of the mass. There was no evidence of pulmonary embolism and the’ operation was otherwise uneventful. Pathological examination of the mass revealed thrombus adherent to an area of infarcted right atria1 tissue. The pericardium showed fibrous thickening. On outpatient review there was good resolution of his signs and symptoms. A repeat computed tomographic scan showed no evidence of an intra-cardiac mass and the patient has been continued on oral anticoagulant therapy. Discussion
Right-sided cardiac thrombi are associated with a high incidence of pulmonary embolism and right heart failure [1,2]. Our report highlights an additional complication, namely tricuspid valve obstruction [3]. This would suggest that surgical thrombectomy followed by oral anticoagulation is the optimal treatment for right atria1 thrombus.
The main causes of intra-cardiac thrombi are blood stasis and endocardial damage. In constrictive pericarditis impaired ventricular filling during diastole causes intra-cardiac stasis. Atria1 fibrillation is common and increases the risk of thrombus formation. Furthermore, there is often myocardial involvement in the disease process which led to cardiac constriction and any residual endocardial abnormalities would promote thrombosis. Despite these predisposing factors there are only 2 previous reports of right atria1 thrombus associated with constrictive pericarditis [4,5]. In both cases atria1 thrombus was an incidental finding. Indeed, the clinical features of a right-sided cardiac mass are similar to those of constriction. Intra-cardiac masses have been visualised by two-dimensional echocardiography, but success is limited by technical considerations as in our case. More accurate detection might be achieved by contrast-enhanced computed tomography. Neither investigation can reliably distinguish between tumour and thrombus but platelet imaging can be used for differentiation [4]. Right atria1 thrombus might be associated with constrictive pericarditis more commonly than previously recognised. The clinical features can be masked by those of cardiac constriction but the presence of thrombus within the right atrium has important clinical and therapeutic implications. Surgical removal of right atria1 thrombus should be considered because of the associated morbidity and mortality. In constrictive pericarditis contrast computed tomography should be performed before pericardiectomy to exclude intracardiac masses.
258 Acknowledgements
We wish to thank Drs D.B. Evans and P. Williams for referring the patient and Dr. N. Cary for the pathological examination.
References
1 Chakko S, Richards F III. Right-sided cardiac thrombi and pulmonary embolism. Am J Cardiol 1987;59:195-196. 2 London AR, Runge PJ, Balsam RF, Bishop MB, Bousvaros
G. Large right atria1 thrombi surrounding permanent transvenous pacemakers. Circulation 1969;40:661-664. 3 Pliam MB, McGough EC, Nixon W, Ruttenberg HD. Right atrial ball-valve thrombus: a complication of central venous alimentation in an infant. J. Thorac Cardiovasc Surg 1979;78:579-582. 4 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;28:1344-1347. 5 Katagiri M, Tanabe Y, Takahashi M, Kasuya S. Right atrial thrombosis: association with constrictive pericarditis. Ann Thorac Surg 1990;49:145-146.
International Journal of Cardiology, 37 (1992) 258-260 0 1992 Elsevier Scientific Publishers Ltd. All rights reserved 0167-5273/92/$05.00
CARD10 15563
Pericardial metastasis and effusion as the initial manifestation of malignant thymoma: identification by cross-sectional echocardiography Wing-Hing Chow, Tsun-Cheung
Chow and Shui-Wah Chiu
Department of Cardiology, Grantham Hospital, Hong Kong, Hong Kong
(Received 25 March 1992; accepted 25 June 1992)
A patient with malignant thymoma is described in whom the initial manifestation effusion which were identified by cross-sectional echocardiography.
was pericardial metastasis and
Key words: Thymoma; Pericardial effusion; Echocardiography
Introduction
Thymoma is the most common primary tumour of the anterior mediastinum [I]. Patients with malignant thymoma might develop the complications of pericar-
dial metastasis and effusion through local invasion. In this report, a patient with malignant thymoma is described in whom the initial manifestation was pericardial metastasis and effusion which were identified by cross-sectional echocardiography. Case Report
Correspondence
to: Dr. W.H. Chow, Dept.
of Cardiology, Grantham Hospital, 125 Wang Chuk Hang Road, Hong Kong,
Hong Kong.
A 76yr-old retired watchman with a l-month history of progressive substernal pain and exertional dysp-
4 Clapp SJ, Perry BL, Farooki ZQ et al. Surgical and medical results of complete atrioventricular canal: a ten year review. Am J Cardiol 1987;59:454-458. 5 Silverman NH, Zuberbuhler JR, Anderson RH, Atrioventricular septal defects: cross-sectional echocardiographic and morphologic comparisons. Int J Cardiol 1986;13:309331.
International Journal of Cardiology, 37 (1992) 2.56-258 0 1992 Elsevier Scientific Publishers Ltd. All rights reserved 0167-5273/92/$05.00
CARD10 15562
Right atria1 thrombus in constrictive pericarditis Kim A. Priestley, John Wallwork and Peter M. Schofield Departments of Cardiology and Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
(Received 10 June 1992; accepted 10 June 1992)
We describe right atria1 thrombus complicated by tricuspid valve obstruction in a patient with constrictive pericarditis. This report highlights the role of surgical thrombectomy, and the investigation of constrictive pericarditis to exclude intra-cardiac thrombus. Key words: Right atria1 thrombus; Constrictive pericarditis
Introduction
Case Report
Right atria1 thrombus is uncommon and usually found in patients with right-sided cardiac abnormalities or foreign bodies [1,2]. Since pulmonary embolism and right heart failure are complications of right atria1 thrombus surgical thrombectomy may be advised. We report a case of constrictive pericarditis, right atria1 thrombus and haemodynamic collapse due to tricuspid valve obstruction during surgery.
A 43-yr-old man was admitted with increasing breathlessness and fatigue 4 months after pericarditis complicated by a moderate pericardial effusion which was managed conservatively. His past medical history included renal failure requiring continuous ambulatory peritoneal dialysis for the last 11 months. Physical examination revealed atria1 fibrillation at 90 beats/min and hypotension, blood pressure 80/60 mmHg with 20 mm of paradox. The jugular venous pressure was raised and he had abdominal distension and peripheral oedema. Echocardiography showed bright pericardial echoes but no pericardial fluid and cardiac constriction was suspected. Haemodynamic studies demonstrated near equalisation of end diastolic pressures in all 4
Correspondence to: Dr. K. Priestley, Dept. of Invasive Cardiol-
ogy, Royal Brompton National Heart & Lung Hospital, Sydney Street, London SW3 6NP, U.K. Tel. 071 351 8625. Fax 071 351 8614.
Fig. 1. Contrast-enhanced computed tomographic scan of mediastinum. Left: transverse section showing a filling defect within the right atrium (arrows). Right: transverse section showing pericardial thickening (arrows).
cardiac chambers and a “dip and plateau” pattern was seen in both ventricles. Coronary angiography was normal. Contrast computed tomography confirmed pericardial thickening and revealed a mass 4 cm in diameter within the right atrium (Fig. 1). Surgery was performed via a median sternotomy. During mobilisation of the heart the patient suffered haemodynamic collapse characteristic of tricuspid valve obstruction with an abrupt rise in right atria1 pressure and a precipitous fall in systemic arterial pressure. The patient responded rapidly when cardiopulmonary bypass was instituted followed by right atriotomy and removal of the mass. There was no evidence of pulmonary embolism and the’ operation was otherwise uneventful. Pathological examination of the mass revealed thrombus adherent to an area of infarcted right atria1 tissue. The pericardium showed fibrous thickening. On outpatient review there was good resolution of his signs and symptoms. A repeat computed tomographic scan showed no evidence of an intra-cardiac mass and the patient has been continued on oral anticoagulant therapy. Discussion
Right-sided cardiac thrombi are associated with a high incidence of pulmonary embolism and right heart failure [1,2]. Our report highlights an additional complication, namely tricuspid valve obstruction [3]. This would suggest that surgical thrombectomy followed by oral anticoagulation is the optimal treatment for right atria1 thrombus.
The main causes of intra-cardiac thrombi are blood stasis and endocardial damage. In constrictive pericarditis impaired ventricular filling during diastole causes intra-cardiac stasis. Atria1 fibrillation is common and increases the risk of thrombus formation. Furthermore, there is often myocardial involvement in the disease process which led to cardiac constriction and any residual endocardial abnormalities would promote thrombosis. Despite these predisposing factors there are only 2 previous reports of right atria1 thrombus associated with constrictive pericarditis [4,5]. In both cases atria1 thrombus was an incidental finding. Indeed, the clinical features of a right-sided cardiac mass are similar to those of constriction. Intra-cardiac masses have been visualised by two-dimensional echocardiography, but success is limited by technical considerations as in our case. More accurate detection might be achieved by contrast-enhanced computed tomography. Neither investigation can reliably distinguish between tumour and thrombus but platelet imaging can be used for differentiation [4]. Right atria1 thrombus might be associated with constrictive pericarditis more commonly than previously recognised. The clinical features can be masked by those of cardiac constriction but the presence of thrombus within the right atrium has important clinical and therapeutic implications. Surgical removal of right atria1 thrombus should be considered because of the associated morbidity and mortality. In constrictive pericarditis contrast computed tomography should be performed before pericardiectomy to exclude intracardiac masses.
258 Acknowledgements
We wish to thank Drs D.B. Evans and P. Williams for referring the patient and Dr. N. Cary for the pathological examination.
References
1 Chakko S, Richards F III. Right-sided cardiac thrombi and pulmonary embolism. Am J Cardiol 1987;59:195-196. 2 London AR, Runge PJ, Balsam RF, Bishop MB, Bousvaros
G. Large right atria1 thrombi surrounding permanent transvenous pacemakers. Circulation 1969;40:661-664. 3 Pliam MB, McGough EC, Nixon W, Ruttenberg HD. Right atrial ball-valve thrombus: a complication of central venous alimentation in an infant. J. Thorac Cardiovasc Surg 1979;78:579-582. 4 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;28:1344-1347. 5 Katagiri M, Tanabe Y, Takahashi M, Kasuya S. Right atrial thrombosis: association with constrictive pericarditis. Ann Thorac Surg 1990;49:145-146.
International Journal of Cardiology, 37 (1992) 258-260 0 1992 Elsevier Scientific Publishers Ltd. All rights reserved 0167-5273/92/$05.00
CARD10 15563
Pericardial metastasis and effusion as the initial manifestation of malignant thymoma: identification by cross-sectional echocardiography Wing-Hing Chow, Tsun-Cheung
Chow and Shui-Wah Chiu
Department of Cardiology, Grantham Hospital, Hong Kong, Hong Kong
(Received 25 March 1992; accepted 25 June 1992)
A patient with malignant thymoma is described in whom the initial manifestation effusion which were identified by cross-sectional echocardiography.
was pericardial metastasis and
Key words: Thymoma; Pericardial effusion; Echocardiography
Introduction
Thymoma is the most common primary tumour of the anterior mediastinum [I]. Patients with malignant thymoma might develop the complications of pericar-
dial metastasis and effusion through local invasion. In this report, a patient with malignant thymoma is described in whom the initial manifestation was pericardial metastasis and effusion which were identified by cross-sectional echocardiography. Case Report
Correspondence
to: Dr. W.H. Chow, Dept.
of Cardiology, Grantham Hospital, 125 Wang Chuk Hang Road, Hong Kong,
Hong Kong.
A 76yr-old retired watchman with a l-month history of progressive substernal pain and exertional dysp-
