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CASE REPORT
Year : 2020  |  Volume : 30  |  Issue : 4  |  Page : 231-233

A right atrial appendage thrombus mimicking a tumor


1 Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Cardiovascular Surgery, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Pathology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran

Date of Submission14-Jul-2020
Date of Web Publication20-Jan-2021

Correspondence Address:
Ali Hosseinsabet
Tehran Heart Center, Karegar Shomali Street, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_78_20

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  Abstract 


A right atrial (RA) mass was incidentally found by transthoracic echocardiography in a 79-year-old man with atrial fibrillation rhythms but without a history of anticoagulation. Transesophageal echocardiography revealed a pedunculated immobile mass in the RA appendage. In addition, some calcification was detected in computed tomography. The mass was excised, and pathological examinations revealed organized thrombosis. Accordingly, in the presence of predisposing factors, thrombi, which may mimic some imaging features of tumors, should be considered in the differential diagnosis of RA masses.

Keywords: Echocardiography, right atrial, thrombus


How to cite this article:
Ahmadi-Renani S, Alidoosti M, Salehi-Omran A, Shahbazi N, Hosseinsabet A. A right atrial appendage thrombus mimicking a tumor. J Cardiovasc Echography 2020;30:231-3

How to cite this URL:
Ahmadi-Renani S, Alidoosti M, Salehi-Omran A, Shahbazi N, Hosseinsabet A. A right atrial appendage thrombus mimicking a tumor. J Cardiovasc Echography [serial online] 2020 [cited 2021 Mar 7];30:231-3. Available from: https://www.jcecho.org/text.asp?2020/30/4/231/307378




  Introduction Top


While cardiac tumors are rare in the general population and most of them are detected incidentally, cardiac thrombi are almost always in the differential diagnosis of cardiac masses.[1] Thrombi may simulate some features of myxomas such as the presence of a stalk[2] and calcification.[3] Herein, we describe an old man with a pedunculated thrombus and some calcification in his right atrial (RA) appendage.


  Case Report Top


A 79-year-old man who suffered from dyspnea of the New York Heart Association functional class II of 3 months' duration referred to our hospital because of an RA mass. The patient was not on medication and had an unremarkable medical history. Physical examinations yielded no significant findings except for bradycardia (heart rate = 45 bpm) with irregular rhythms. Electrocardiography demonstrated atrial fibrillation rhythms. Laboratory tests were unremarkable except for the thyroid function test, which was suggestive of hypothyroidism. For further evaluation, transthoracic and transesophageal echocardiographic examinations were performed; they revealed a large and round heterogeneous mobile mass (58 mm × 30 mm) with some calcification attached to the RA appendage through a stalk. [[Figure 1] & video 1] The left atrial appendage was free of thrombosis. The other findings included normal left ventricular size and function (ejection fraction ≈55%), moderate right ventricular enlargement with mild systolic dysfunction, biatrial enlargement, and moderate tricuspid regurgitation (peak pressure gradient = 30 mmHg). Three-dimensional echocardiography better delineated the RA mass. Coronary computed tomography angiography illustrated no significant stenosis; nonetheless, it showed the RA mass with small calcification as an ancillary finding. The patient underwent surgical RA appendage mass resection. Pathological examinations demonstrated organized thrombosis. He was discharged in good condition.
Figure 1: (a) A heterogeneous mass is attached to the right atrial appendage through a stalk in the bicaval view of transesophageal echocardiography. The mass appears in the upper esophageal view at 0° (b) and 47° (c). Three-dimensional echocardiography delineates the mass (d and e) calcification (arrow) is detected in the right atrial appendage mass (*) in coronary computed tomography angiography as an ancillary finding

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  Discussion Top


Atrial fibrillation undermines the function of the RA appendage,[4] so the occurrence of thrombosis in the RA appendage can be anticipated. The incidence of thrombi in the RA appendage in patients with atrial fibrillation is <1%, and approximately 57% of the cases of thrombosis in the left atrial appendage are free of clots.[5] RA thrombosis may be associated with pulmonary embolism or cerebrovascular events in the presence of a patent foramen ovale,[6] although such possible associations are open to debate.[7]

RA thrombi that are highly mobile and serpiginous are associated with deep vein thrombosis in that that their embolization and subsequent transit to the pulmonary artery could lead to their entrapment in the RA. Immobile RA thrombi are formed in situ.[8]

In our patient, atrial fibrillation was the most probable etiology for the formation of the thrombus in the RA appendage. It has been previously posited that these calcified masses are originally tumors that degenerate and create a nidus for thrombus formation and calcification.[9]

In the case of our patient, the presence of calcification in the mass, together with its attachment via a stalk to the RA appendage, was in favor of an RA tumor (e.g., a myxoma).[10] It is noteworthy that calcified RA thrombi have been previously reported.[2],[9],[11] Our heart team's first decision was to dissolve the thrombus with anticoagulants; nevertheless, the size of the thrombus prompted them to opt for surgery without further evaluation.


  Conclusions Top


It can, therefore, be concluded that in the setting of atrial fibrillation, cardiologists should investigate the presence of RA thrombi because such thrombi may exist in the absence of the left atrial thrombosis. Some imaging features of tumors such as the presence of calcification and stalk may exist in the presence of organized thrombi, and thrombi should be considered in the differential diagnosis of pedunculated RA masses with calcification.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mankad R, Herrmann J. Cardiac tumors: Echo assessment. Echo Res Pract 2016;3:R65-77.  Back to cited text no. 1
    
2.
Cuminetti G, Lutea ML, De Keyzer EL, Morissens M. Right atrial pedunculated mass: Myxoma or thrombus? J Cardiovasc Med (Hagerstown) 2019;20:105-6.  Back to cited text no. 2
    
3.
Haji K, Nasis A. Radiological characteristics of atrial myxoma in cardiac computed tomography. J Cardiovasc Comput Tomogr 2017;11:234-6.  Back to cited text no. 3
    
4.
Sahin T, Ural D, Kilic T, Bildirici U, Kozdag G, Agacdiken A, et al. Right atrial appendage function in different etiologies of permanent atrial fibrillation: A transesophageal echocardiography and tissue Doppler imaging study. Echocardiography 2010;27:384-93.  Back to cited text no. 4
    
5.
Cresti A, García-Fernández MA, Miracapillo G, Picchi A, Cesareo F, Guerrini F, et al. Frequency and significance of right atrial appendage thrombi in patients with persistent atrial fibrillation or atrial flutter. J Am Soc Echocardiogr 2014;27:1200-7.  Back to cited text no. 5
    
6.
Huang G, Pavan D, Antonini-Canterin F, Piazza R, Cassin M, Nicolosi GL, et al. Thrombus in the right atrial appendage during pulmonary and paradoxical embolism: A case report. Ital Heart J 2002;3:486-9.  Back to cited text no. 6
    
7.
Ptaszynska-Kopczynska K, Kiluk I, Sobkowicz B. Atrial fibrillation in patients with acute pulmonary embolism: Clinical significance and impact on prognosis. Biomed Res Int 2019;2019:7846291.  Back to cited text no. 7
    
8.
Português J, Calvo L, Oliveira M, Pereira VH, Guardado J, Lourenço MR, et al. Pulmonary embolism and intracardiac type A thrombus with an unexpected outcome. Case Rep Cardiol 2017;2017:9092576.  Back to cited text no. 8
    
9.
Yamane Y, Morimoto H, Okubo S, Koshiyama H, Mukai S. Right atrial calcified ball thrombus mimicking a myxoma. Heart Lung Circ 2016;25:e21-3.  Back to cited text no. 9
    
10.
Sanjeev OP, Nath SS, Malviya D, Rajput SS. Right atrial myxoma: Unusual location; uncommon association. Ann Card Anaesth 2018;21:437-9.  Back to cited text no. 10
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11.
Mujanovic E, Bergsland J, Jurcic S, Avdic S, Stanimirovic-Mujanovic S, Kabil E, et al. Calcified right atrial and pulmonary artery mass after ventriculoatrial shunt insertion. Med Arh 2011;65:363-4.  Back to cited text no. 11
    


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