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Intracardiac masses are rare and their exact nature is often difficult to ascertain by conventional imaging methods alone. A 40 year old white woman presented with a six month history of progressive dyspnoea, orthopnoea, and peripheral oedema. Clinically she had signs of biventricular failure. Images from her transthoracic echocardiogram showed a large left atrial mass causing critical functional mitral stenosis (below left and right). A differential diagnosis of vegetation, thrombus, myxoma or other cardiac tumour (for example, lymphoma) was considered. A thrombophilia screen demonstrated raised serum concentrations of both anticardiolipin antibody (aCL) and antibody to its cofactor, β2 glycoprotein I (β2GPI) on two separate occasions. An autoimmune profile (including antinuclear antibody and antibodies to extractable nuclear antigens) was negative, confirming the diagnosis of primary antiphospholipid syndrome.
The patient was initially managed with high intensity anticoagulation, but failed to improve on clinical or echocardiographic criteria, and therefore surgical resection of the mass was performed. Histopathological analysis of the mass confirmed old and recent thrombus undergoing organisation from the base and infiltrated by reactive macrophages. This case highlights the need to screen all patients with intracardiac masses of unknown aetiology for prothrombotic disorders.
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