Clinical and echocardiographic features of right atrial masses

Presented is a single-case of a novel technique of catheter-directed thrombolysis via an existing implanted venous-access port for treatment of a right atrial thrombus.

A 51-year-old woman with metastatic colon cancer, being treated with chemotherapy via a MediPort was found to have a large right atrial thrombus (2.8 × 4.7 × 2.3 cm) adjacent to the MediPort tip on follow-up chest CT. The patient received three months of anticoagulation without improvement. Due to the location of the thrombus, the patient was treated with continuous infusion of tissue plasminogen activator through the MediPort at a rate of 1 mg/hr for 24 h.

Transthoracic echocardiogram at 24 h demonstrated no visible thrombus. 1 month follow up TTE revealed resolution of RA thrombus.

A catheter-directed thrombolysis is the effective approach to treat a catheter induced thrombus, while lowering the systemic risk of thrombolytic therapy.

Floating right heart thrombi (FRHTS) are a rare phenomenon associated with high mortality. Immediate treatment is mandatory, but optimal therapy is controversial.

To compare the clinical characteristics according to different treatment strategies and to identify predictors of mortality on patients with FRHTS.

We conducted a systematic search of reported clinical cases of TTRH from 2006 to 2016.

207 patients were analyzed, median age was 60 years, 51.7% were men, 31.4% presented with shock. Pulmonary thromboembolism was present in 85% of the cases. The treatments administered were anticoagulation therapy in 44 patients (21.28%), surgical embolectomy in 89 patients (43%), thrombolytic therapy in 66 patients (31.8%), percutaneous thrombectomy in 3 patients (1.93%) and fibrinolytic in situ in 4 (1.45%). The overall mortality rate was 21.3%. The mortality associated with anticoagulation alone was higher than surgical embolectomy or thrombolysis (36.4 vs 18% vs 18.2%, respectively, p = 0.03), and in percutaneous thrombectomy and fibrinolytics in situ was 0%. At multivariate analysis, only anticoagulation alone (odds ratio [OR] 2.4, IC 95% 1.07–5.4, p = 0.03), and shock (OR 2.87 (IC 95% 1.3–5.9, p = 0.005) showed a statistically significant effect on mortality.

FRHTS represent a serious form of thromboembolism that requires rapid decisions to improve the survival. Anticoagulation as the only strategy does not seem to be sufficient, while thrombolysis and surgical thrombectomy show better and similar results. A proper individualization of the risk and benefits of both techniques is necessary to choose the most appropriate strategy for our patients.

Right-sided cardiac masses are infrequent and have varied clinical presentation. The present study describes the clinical features, echocardiographic findings and management of 19 patients presenting with right-sided cardiac thrombi in a tertiary care center in north India.

This is a retrospective, single center observational study of consecutive patients over the period January 2003–2008 admitted in our emergency intensive care unit (EICU). We identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by transthoracic echocardiography of which 19 patients had right-sided thrombus. The echocardiographic findings were reviewed by two cardiologists in all patients. Treatment was not standardized and choice of therapy was based on judgment of attending physician.

The mean age of patients with cardiac thrombus was 36.6 ± 11.8 years. Right atrial (n = 17) and right ventricle (n = 2) thrombi were associated with deep vein thrombosis (DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients appeared to have in situ mural thrombus. 12 patients were managed with oral anticoagulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors had a mean follow-up of 40 ± 6 months (range – 18–50 months).

Prompt echocardiographic examination in an appropriate clinical setting facilitates faster diagnosis and management of patients with right-sided cardiac thrombi. High incidence of in situ mural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and thrombolysis appear to be the mainstay of treatment with surgery limited for selected patients.

Cardiac myxomas are rare benign and slowly proliferating neoplasms of uncertain histogenesis with heterogeneous histomorphology and variable and sometimes clinically quite malignant pathological manifestations. Majority of cardiac myxoma occur sporadically while a relatively small proportion of diagnosed cases develop as a part of Carney complex syndrome with established familial pattern of inheritance. Although histologically indistinguishable these two forms of cardiac myxoma exhibit distinct cytogenetic make-up and apparent pathological differences important for their clinical presentation and prognosis. Additional problem is presented with secondary lesions with more aggressive histology and significantly faster cell proliferation suggesting their successive malignant alteration. Surgical resection of cardiac myxoma is currently the only treatment of choice. However, to avoid potentially hazardous operating procedures and possible postoperative complications and to prevent recurrence of the neoplastic lesions it is necessary to develop alternative approaches and identify a possible drug targets for their successful pharmacological treatment. Due to the rarity of the disease, a small number of cases in one institution and lack of comprehensive experimental data particularly concerning the cases of metastatic dissemination and secondary lesions with malignant nature, a comprehensive multi-institutional approach is required for better understanding of their molecular pathology and illumination of key molecular, genetic as well as epigenetic markers and regulatory pathways responsible for their development. In this article we provide comprehensive pathohistological, molecular and cytogenetic overview of sporadic cardiac myxoma cases restating the major hypothesis concerning their histogenesis and emphasizing potential approaches for their further reexamination.

Intracardiac thrombus formation usually occurs in the left-sided cavities of the heart, most frequently in the presence of atrial fibrillation or cardiomyopathy. We report the case of an initially unclear mass developing in the right atrium (RA) of a heart transplant recipient, which was subsequently resected via a minimally invasive surgical approach. Access via right anterior minithoracotomy using videoscopic assistance allowed for uncomplicated RA thrombectomy in the presented case, avoiding reentry sternotomy with the potential risk of cardiac injury and without aortic cross-clamping or cardioplegic arrest. The patient is doing fine with excellent graft function at the latest follow-up 4 months after minimally invasive thrombectomy and 30 months after cardiac transplantation. To the best of our knowledge, this is the first report describing minimally invasive resection of a right atrial thrombus in a heart transplant recipient.