|Year : 2018 | Volume
| Issue : 4 | Page : 242-244
Thrombus formation in the right atrium after surgical closure of atrial septal defect
Muzaffer Kahyaoglu1, Ahmet Guner2, Cetin Gecmen2
1 Department of Cardiology, Umraniye Training and Research Hospital, Istanbul, Turkey
2 Department of Cardiology, Kartal Kosuyolu Heart and Research Hospital, Istanbul, Turkey
|Date of Web Publication||24-Dec-2018|
Department of Cardiology, Umraniye Training and Research Hospital, Umraniye, 34764, Istanbul
Source of Support: None, Conflict of Interest: None
Atrial septal defect is the most common congenital lesion in adults following bicuspid aortic valve. There are two closure strategies as follows: one surgical and the other percutaneous. Various complications such as atrial arrhythmias and development of thrombus have been reported after surgical closure. Herein, we present a case of right atrial thrombi formed at different localizations in the right atrium in a patient who was asymptomatic and diagnosed late.
Keywords: Atrial septal defect, right atrium, thrombus
|How to cite this article:|
Kahyaoglu M, Guner A, Gecmen C. Thrombus formation in the right atrium after surgical closure of atrial septal defect. J Cardiovasc Echography 2018;28:242-4
|How to cite this URL:|
Kahyaoglu M, Guner A, Gecmen C. Thrombus formation in the right atrium after surgical closure of atrial septal defect. J Cardiovasc Echography [serial online] 2018 [cited 2019 Mar 21];28:242-4. Available from: http://www.jcecho.org/text.asp?2018/28/4/242/248409
| Introduction|| |
Atrial septal defect (ASD) is the most common congenital lesion in adults following bicuspid aortic valve. Although this defect is often asymptomatic until adulthood, it should nevertheless be considered because of the potential complications of ASD closure. There are two closure strategies: surgical and percutaneous. Percutaneous transcatheter device closure is an alternative to surgical repair for the majority of patients with ostium secundum ASD. Surgical closure is recommended in patients with ostium secundum ASD requiring closure when percutaneous repair is not feasible or appropriate. Various complications such as atrial arrhythmias and development of thrombus have been reported after surgical closure., Herein, we present a case of right atrial thrombi formed at different localizations in the right atrium in a patient who was asymptomatic and diagnosed late.
| Case Report|| |
A 52-year-old male patient who had surgical closure of an ostium secundum type ASD with pericardial patch 6 months previously presented to our cardiology outpatient clinic for routine follow-up. His medication included acetylsalicylic acid 100 mg and clopidogrel 75 mg, daily. Physical examination was unremarkable. The electrocardiography showed normal sinus rhythm and incomplete right bundle branch block. Transthoracic echocardiography apical four-chamber view showed an intact ASD patch and no leaks, but there was a thrombus formation of 3.5 cm × 2.1 cm on the right atrium [Figure 1]a. There was no right ventricular dilatation, and pulmonary artery systolic pressure was estimated to be within normal limits. Transesophageal echocardiography (TEE) was planned. TEE midesophageal 43° view showed a thin pedicle handle thrombus formation in the inferior vena cava cannulation site [[Figure 1]b and Video 1]. Furthermore, another thrombus attached to the ASD patch could be seen in the TEE midesophageal bicaval view [[Figure 1]c and Video 2]. Three-dimensional TEE (3D TEE) midesophageal bicaval view showed the formation of two thrombi [[Figure 1]d and Video 3]. Detailed coagulation and genetic tests revealed no coagulation abnormality. The patient was prescribed medical treatment due to the lack of symptoms, and anticoagulant therapy was initiated.
|Figure 1: (a) Transthoracic echocardiography apical four chamber view showed an intact atrial septal defect patch and no leaks, but there was a thrombus formation of 3.5 cm × 2.1 cm on the right atrium. (b) Transesophageal echocardiography midesophageal 430 view showed a pedincle handle (arrow) thrombus formation in the inferior vena cava cannulation site. (c) Transesophageal echocardiography midesophageal bicaval view showed another thrombus attached to the atrial septal defect patch. (d) Three-dimensional transesophageal echocardiography midesophageal bicaval view showed formation of two thrombi (arrows)|
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| Discussion|| |
Atrial thrombi occurring in the postoperative period following ASD patch closure is a rare condition. Thrombus formation may be seen in the early or late postoperative period., It usually takes the form of an acute thromboembolic complication after both device and surgical patch-based repairs of ASD,, but as seen in our cases, it can be diagnosed late. Clinical representation in patients may present across a broad spectrum ranging from asymptomatic to atypical chest pain or exertional dyspnea. Some cases of pulmonary embolism due to thrombus formation have been reported and may be fatal., Thrombus formation may occur on occluder devices, patches, or primary suture regions.,, In our case, the formation of two thrombi originated from the site of atrial trauma by suction and on the suture in the pericardial patch area. The suture line serves as the nidus for thrombus formation and facilitates it.
Treatment of atrial thrombi is controversial with medical, surgical procedures, and percutaneous interventional techniques can be applied. Thrombolytic therapy may be preferred in cases of life-threatening pulmonary embolism due to the thrombus formation. However, when using thrombolytic agents, there is a risk that the dissolution of the thrombus pedicle may lead to migration and embolization; furthermore, thrombolytic therapy itself can cause pulmonary embolism, especially in large thrombi that are thin pedicle handle. The need for surgery in these cases can be considered only if the thrombus increases in size or if signs of peripheral/systemic embolization are present despite a period of adequate anticoagulation therapy. In general, percutaneous treatments are preferred in cases where thrombolytic therapy or surgery is contraindicated. Atrial thrombus therapy should be personalized, and conditions such as the patient's clinical presentation, thrombolytic therapy, or surgical contraindications should be considered. In our case, anticoagulant therapy was preferred as a treatment option because the patient was asymptomatic, and there was the possibility of embolic complication after interventional or thrombolytic therapy because the thrombus was attached by a thin pedicle handle.
| Conclusion|| |
We have illustrated an asymptomatic case that developed two atrial thrombi diagnosed through two-dimensional and 3D TEE views. Rarely, atrial thrombi may develop in the postoperative period following ASD patch closure. Echocardiography plays an important role for the early detection and management of such complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al.
ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation 2008;118:e714-833.
Bhukar RK, Gowda D, Rao JN, Desai N. Management of atrial thrombus formation following surgical closure of an atrial septal defect. J Card Surg 2017;32:476-8.
Wasmer K, Köbe J, Dechering DG, Bittner A, Mönnig G, Milberg P, et al.
Isthmus-dependent right atrial flutter as the leading cause of atrial tachycardias after surgical atrial septal defect repair. Int J Cardiol 2013;168:2447-52.
Disli OM, Erdil N, Akca B, Otlu YO, Battaloglu B. Large thrombus formation from right atrial incision site after closure of atrial septal defect. Korean Circ J 2013;43:842-4.
Dinckal MH, Davutoglu V, Soydinc S, Akdemir I, Aksoy M. Large thrombus at the site of primary sutured atrial septal defect associated with pulmonary embolism and treatment by thrombolysis. Echocardiography 2003;20:535-8.
Chessa M, Carminati M, Butera G, Bini RM, Drago M, Rosti L, et al.
Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol 2002;39:1061-5.
Hawe A, Rastelli GC, Brandenburg RO, McGoon DC. Embolic complications following repair of atrial septal defects. Circulation 1969;39:I185-91.
Sheikh AY, Schrepfer S, Stein W, West J, Lombard J, Burdon T, et al.
Right atrial mass after primary repair of an atrial septal defect: Thrombus masquerading as a myxoma. Ann Thorac Surg 2007;84:1742-4.
Hwang YJ, Ahn YC, Lee CH, JeonYB, Lee JW, Park CH, et al
. Surgical removal of large thrombus at the suture site of the right atriotomy after atrial septal defect closure associated with pulmonary embolism: 1 case. Korean J Thorac Cardiovasc Surg 2004;37:448-51.
Chartier L, Béra J, Delomez M, Asseman P, Beregi JP, Bauchart JJ, et al.
Free-floating thrombi in the right heart: Diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779-83.