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Detection of round floating left atrial thrombus simulating left atrial myxoma by two-dimensional echocardiography
August,
492
Brief
Communications
American
Detection of round floating left atrial thrombus simulating left atrial myxoma two-dimensional echocardiography
Heart
1985 Journal
by
Chen Zur-Binenboim, M.D., Rony Ammar, M.D., Ehud Grenadier, M.D., Alexander Veisler, M.D., Moshe Freud, M.D., and Avraham Palant, M.D. Haifa,
Israel
A caseof round left atria1 (LA) thrombus, simulating LA myxoma, is demonstrated by echocardiography, followed by dislodgement of the thrombus 22 hours later to the right leg. After a Fogarty catheter procedure, no traces of atria1 masscould be seen on repeated echocardiograms. Histologic examination confirmed the diagnosisof thrombus. To the best of our knowledge, this is the first case report of a left atria1 thrombus detected by echocardiogram, and dislodged completely. A 73-year-old woman was admitted to the hospital because of palpitations and weakness,which started 3 days preceding admission. Her past medical history was noncontributory. The physical examination was normal, apart from an irregular pulse. Her blood pressure was 110/75 mm Hg. Cardiac examination was normal; no murmurs or clicks were heard. No neurologic deficit was noticed. An ECG demonstrated slow atria1 fibrillation with ventricular response of 80 to 90 bpm and minor anterior wall ST-T changes. Chest roentgenogram was normal, as were routine blood laboratory examinations, including thyroid function tests. Routine echocardiographic examination was normal, except for a floating mass1 x 2 cm in the normal left atrium, that wasattached to the intra-atria1 septum by a short pedicle (Fig. 1). The diagnosisof a left atria1 mass (thrombus or tumor) was made,and the patient was therefore prepared for surgery. Twenty-two hours later, the patient complained of sudden, severepain in her right leg. The color waswhite below the knee, and the leg was cold and pulseless.Doppler examination confirmed the disappearanceof pulsesbelow the femoral artery. A Fogarty catheter was inserted through an incision in the upper thigh, and a thrombus, measuring 2 X 2 cm, was removed from the popliteal artery. On repeated echocardiograms,no masscould be visualized in the left atrium (Fig. 2). Histologic examination confirmed the diagnosisof a thrombus. The patient was treated with heparin and warfarin sodium, and was dischargedin a good, clinical condition 2 weekslater, LA thrombus is found especially in patients with mitral stenosiswith enlarged left atrium, in patients after mitral valve replacement, in low cardiac output states, and in patients with atria1 arrhythmias.‘~” Systemic embolization From the Departments and Cardiology, Lady Reprint A, Lady
of Internal Davis Cannel
Medicine Hospital.
A, Cardiothoracic
Surgery,
requests: Chen Zur-Binenhoim, M.D., Dept. of Internal Medicine Davis Carmel Hospital, 7, Michal St., 34 362 Haifa, Israel.
Fig. 1. Two-dimensional echocardiogram, long-axis plane, exhibiting a sessile thrombus attached to the interatrial septum by a short pedicle. RV = right ventricle; LV = left ventricle; A0 = aortic root; LA = left atrium; T = thrombus.
2. Two-dimensional echocardiogram, long-axis plane, exhibiting a normal left atria1 cavity after dislodgement of the thrombus. RV = right ventricle; PM = papillary muscle; LV = left ventricle; AV = aortic valve; LA = left atrium. Fig.
has been reported to originate from rheumatic heart disease with an incidence of 10% to 40%.I-* Today, M-mode echocardiography, and especially two-dimensional echocardiography, are perhaps the most important modalities for imaging LA thrombi. M-mode echocardiography is unreliable for diagnosing LA thrombi.” Twodimensional echocardiography has recently been used successfully in preoperative detection of LA thrombus. However, only a few caseshave been reported,Y,“’ I” and the sensitivity and specificity of this modality in the detection of LA thrombi have not as yet been ascertained.‘~‘~“~~‘” Recently, high sensitivity in detecting LA thrombus with computed tomography has been reported Ii
Volume Number
110 2
Brief Commun?cntions 493
We present the first case report of a LA thrombus detected on routine two-dimensional echocardiography, which later dislodged completely to a peripheral artery. Our case represents a typical example of a patient with systemic embolization, and it is our suggestion that a two-dimensional echocardiogram should be used routinely in any adult patient with atria1 fibrillation, so that by detecting left ventricular or left atria1 masses and by initiating anticoagulant therapy, systemic embolization, which can otherwise be fatal, can be prevented. However, it. is also generally accepted that a negative echocardiographic study does not fully exclude the possibility that heart thrombus is present, or that some thrombus has remained following apparent embolism. REFERENCES
1. De
Pace
NL,
Soul~n
RL,
Kotler
MN,
Mintz
GS:
Two-
dimensional echocardiographic detection of intra-atrial masses. 2.
Am J Cardiol
48:954,
1981.
Mike11 FL, Asinger RW. Rourke T, Hodges M, Sharma H. Francis CJS:Two-dimensional echocardiographic demonstration of left atrial thromhi in patients with prosthetic mitral
valves. Circulation 60:118:i. 1979. ‘3. Braunwauld E: Valvular heart disease. In Braunwauld E. editor: Heart disease: A textbook of cardiovascular medicine. Philadelphia. 1980, W.B. Saunders Co. D. 1095. 4. Parker BH. Friedberg MJ, Templeton AW, Burford T: Preoperative angiocardiographic diagnosis of left atria1 thrombus in mitral stenosis. N Engl J Med 273:136, 1965. 5. Lewis KB. Criely JM. Ross RS: Detection of left atria] t.hrombus in cineangiography. AM HEART J 70:612, 1965. 6. Nichois HT, Blanco G, Morse DP, Adam A, Baltone N: Open mitral commissurotomy: Experience with 200 consecutive cases. .JAMA 182:268, 196X. 7. Billig DM, Hallman GL. Cooley DA: Adrenal embolism. Arch Surg 951, 1967. 8. Young JR, Humphries AW. Dewolfe VG, Lefevre FA: Peripheral arterial embolism. .JAMA 185621, 1963. 9. Furuse A. Mizuno A, Inoue H, Futuza N, Saigusa H, Harada Y: Echocardiography and angiography for detection of left, atrial thrombus. Jpn Heart J 17:163, 1976. 10 Seward ,JB, Gura GM, Hagler DJ. Tajik AJ: Evaluation of M-mode echocardiography and wide angle two-dimensional sector echocardiography in the diagnosis of intracardiac masses (abst). Circulation 58fsuppl II):234, 1978. K, Orita Y. Tanaka S, Kikuchi Y, Nakamura M, 11 Sunagawa Hizata ‘I: Left atria1 hall thrombus diagnosed by twodimensional echocardiography. AM HEART J 100:89, 1980. 12. Schweizer P, Bardos P, Erhel R. Meyer J, Merx W, Messmer B.J, Effert S: Detection of left atria1 thrombi by echocardiography. Br Heart d 45148. 1981. 13. Shrestha NK, Moreno FL, Narcisco FV, Torres L, Calleja HB: Two-dimensional echocardiographic diagnosis of left atria1 thrombus in rheumatic heart disease. Circulation 67~941, 198X 14. Furukawa K. Katsume H, Matsukubo H, Inoub D: Echocardiographic findings of fioat.in p thrombus in left atrium. Br Heart d 44:599. 1980. H. Hoshiai M, Furuya H, Kuribayashi S, Ootaki M, 15. Tomoda Matsuyama S, Koide S. Kawada S, Shotsu A: Evaluation of intracardiac thrombus with computed tomography. Am d Cardiol 5 1:843, 1983. 16. Tallwry MD, Depasquale NP: Ultrasound cardiography in the diagnosis of atria1 thrombus. Chest 59:501, 1971. 17. Spangler RD, Okin .JT: Echocardiographic demonstration of a left atria1 thrombus. Chest 67:716, 1975. 18. Denbow CE, Tajik AJ, Seward JB, Pluth JR: Massive thrombus in body of left atrium. Clinical profile and surgical experience (abst). Circulation 58(suppl II):Z32, 1978.
Constrictive pericarditis following myocardial revascularization: A possible cause of graft occlusion Sami S. Kabbani, M.D., Tali Bashour, M.D., David G. Ellertson, M.D., JamesGeiger, M.D., Elias S. Hanna, M.D. and Tsung 0. Cheng, M.D. San Francisco,
Calif., and Washington.
DC.
Constrictive pericarditis following aortocoronary bypass operations has infrequently been reported in the literature.‘-” Furthermore, only in one report’ was a form of pericarditis (the post pericardiotomy syndrome) incriminated in the production of graft occlusion. We describe here our experience with four patients who underwent aortocoronary bypass operations and developed an early post operative pericarditis resulting in graft occlusion in all four patients and myocardial constriction in three of these. The four patients were seenwithin a spanof 2 years and 3 months. During the sameperiod, 1158open-heart operations were carried out at our institution. The first patient, a 53-year-old man, wasfirst admitted to our hospital with inferior myocardial infarction. He remained asymptomatic for 10 years afterwards, then was readmitted with exertional angina. Cardiac catheterization revealed total occlusion of the right coronary (RC) artery and severe proximal stenosisof the left anterior descending (LAD) and circumflex (CX) arteries. The patient underwent aortocoronary bypassto the LAD and obtuse marginal (OM) branches.His postoperative course was marked by the appearanceof a pericardial rub and widened mediastinum 4 days after operation, and an echocardiogramwas suggestiveof the presenceof a large amount of anterior pericardial effusion. His jugular veins becamedistended and a 16 mm Hg pulsusparadoxus was detected. Serial roentgenograms of the chest revealed gradual resolution of effusion. Seven weeks after operation, the patient was readmitted with obvious manifestations of myocardial constriction. Right heart catheterization was consistent with constrictive pericarditis. At operation a desmoplasticreaction wasfound involving the anterior mediastinal tissues. The RC and OM grafts appearedengulfed in the thick pericardial peel. Decortication starting with the left ventricle was carried out, and the grafts were freed. The postoperative course was uneventful. The secondpatient, a %-year-old man, wasfirst admitted with a recent history of exertional angina. He had sustainedtwo myocardial infarctions 7 and 2 years prior to admission.Cardiac catheterization revealed severe occluFrom the Western Medical Center. Reprint Mary’s 9411;
requests: Hospital
Heart
Institute;
Tali T. Bashour, 6i Medical Center,
and
the Geor.re
Wwhington
M.D.. Western Heart 4.50 Stanvan St.. San
University Institute. Francisco.
St. CA
492
Brief
Communications
American
Detection of round floating left atrial thrombus simulating left atrial myxoma two-dimensional echocardiography
Heart
1985 Journal
by
Chen Zur-Binenboim, M.D., Rony Ammar, M.D., Ehud Grenadier, M.D., Alexander Veisler, M.D., Moshe Freud, M.D., and Avraham Palant, M.D. Haifa,
Israel
A caseof round left atria1 (LA) thrombus, simulating LA myxoma, is demonstrated by echocardiography, followed by dislodgement of the thrombus 22 hours later to the right leg. After a Fogarty catheter procedure, no traces of atria1 masscould be seen on repeated echocardiograms. Histologic examination confirmed the diagnosisof thrombus. To the best of our knowledge, this is the first case report of a left atria1 thrombus detected by echocardiogram, and dislodged completely. A 73-year-old woman was admitted to the hospital because of palpitations and weakness,which started 3 days preceding admission. Her past medical history was noncontributory. The physical examination was normal, apart from an irregular pulse. Her blood pressure was 110/75 mm Hg. Cardiac examination was normal; no murmurs or clicks were heard. No neurologic deficit was noticed. An ECG demonstrated slow atria1 fibrillation with ventricular response of 80 to 90 bpm and minor anterior wall ST-T changes. Chest roentgenogram was normal, as were routine blood laboratory examinations, including thyroid function tests. Routine echocardiographic examination was normal, except for a floating mass1 x 2 cm in the normal left atrium, that wasattached to the intra-atria1 septum by a short pedicle (Fig. 1). The diagnosisof a left atria1 mass (thrombus or tumor) was made,and the patient was therefore prepared for surgery. Twenty-two hours later, the patient complained of sudden, severepain in her right leg. The color waswhite below the knee, and the leg was cold and pulseless.Doppler examination confirmed the disappearanceof pulsesbelow the femoral artery. A Fogarty catheter was inserted through an incision in the upper thigh, and a thrombus, measuring 2 X 2 cm, was removed from the popliteal artery. On repeated echocardiograms,no masscould be visualized in the left atrium (Fig. 2). Histologic examination confirmed the diagnosisof a thrombus. The patient was treated with heparin and warfarin sodium, and was dischargedin a good, clinical condition 2 weekslater, LA thrombus is found especially in patients with mitral stenosiswith enlarged left atrium, in patients after mitral valve replacement, in low cardiac output states, and in patients with atria1 arrhythmias.‘~” Systemic embolization From the Departments and Cardiology, Lady Reprint A, Lady
of Internal Davis Cannel
Medicine Hospital.
A, Cardiothoracic
Surgery,
requests: Chen Zur-Binenhoim, M.D., Dept. of Internal Medicine Davis Carmel Hospital, 7, Michal St., 34 362 Haifa, Israel.
Fig. 1. Two-dimensional echocardiogram, long-axis plane, exhibiting a sessile thrombus attached to the interatrial septum by a short pedicle. RV = right ventricle; LV = left ventricle; A0 = aortic root; LA = left atrium; T = thrombus.
2. Two-dimensional echocardiogram, long-axis plane, exhibiting a normal left atria1 cavity after dislodgement of the thrombus. RV = right ventricle; PM = papillary muscle; LV = left ventricle; AV = aortic valve; LA = left atrium. Fig.
has been reported to originate from rheumatic heart disease with an incidence of 10% to 40%.I-* Today, M-mode echocardiography, and especially two-dimensional echocardiography, are perhaps the most important modalities for imaging LA thrombi. M-mode echocardiography is unreliable for diagnosing LA thrombi.” Twodimensional echocardiography has recently been used successfully in preoperative detection of LA thrombus. However, only a few caseshave been reported,Y,“’ I” and the sensitivity and specificity of this modality in the detection of LA thrombi have not as yet been ascertained.‘~‘~“~~‘” Recently, high sensitivity in detecting LA thrombus with computed tomography has been reported Ii
Volume Number
110 2
Brief Commun?cntions 493
We present the first case report of a LA thrombus detected on routine two-dimensional echocardiography, which later dislodged completely to a peripheral artery. Our case represents a typical example of a patient with systemic embolization, and it is our suggestion that a two-dimensional echocardiogram should be used routinely in any adult patient with atria1 fibrillation, so that by detecting left ventricular or left atria1 masses and by initiating anticoagulant therapy, systemic embolization, which can otherwise be fatal, can be prevented. However, it. is also generally accepted that a negative echocardiographic study does not fully exclude the possibility that heart thrombus is present, or that some thrombus has remained following apparent embolism. REFERENCES
1. De
Pace
NL,
Soul~n
RL,
Kotler
MN,
Mintz
GS:
Two-
dimensional echocardiographic detection of intra-atrial masses. 2.
Am J Cardiol
48:954,
1981.
Mike11 FL, Asinger RW. Rourke T, Hodges M, Sharma H. Francis CJS:Two-dimensional echocardiographic demonstration of left atrial thromhi in patients with prosthetic mitral
valves. Circulation 60:118:i. 1979. ‘3. Braunwauld E: Valvular heart disease. In Braunwauld E. editor: Heart disease: A textbook of cardiovascular medicine. Philadelphia. 1980, W.B. Saunders Co. D. 1095. 4. Parker BH. Friedberg MJ, Templeton AW, Burford T: Preoperative angiocardiographic diagnosis of left atria1 thrombus in mitral stenosis. N Engl J Med 273:136, 1965. 5. Lewis KB. Criely JM. Ross RS: Detection of left atria] t.hrombus in cineangiography. AM HEART J 70:612, 1965. 6. Nichois HT, Blanco G, Morse DP, Adam A, Baltone N: Open mitral commissurotomy: Experience with 200 consecutive cases. .JAMA 182:268, 196X. 7. Billig DM, Hallman GL. Cooley DA: Adrenal embolism. Arch Surg 951, 1967. 8. Young JR, Humphries AW. Dewolfe VG, Lefevre FA: Peripheral arterial embolism. .JAMA 185621, 1963. 9. Furuse A. Mizuno A, Inoue H, Futuza N, Saigusa H, Harada Y: Echocardiography and angiography for detection of left, atrial thrombus. Jpn Heart J 17:163, 1976. 10 Seward ,JB, Gura GM, Hagler DJ. Tajik AJ: Evaluation of M-mode echocardiography and wide angle two-dimensional sector echocardiography in the diagnosis of intracardiac masses (abst). Circulation 58fsuppl II):234, 1978. K, Orita Y. Tanaka S, Kikuchi Y, Nakamura M, 11 Sunagawa Hizata ‘I: Left atria1 hall thrombus diagnosed by twodimensional echocardiography. AM HEART J 100:89, 1980. 12. Schweizer P, Bardos P, Erhel R. Meyer J, Merx W, Messmer B.J, Effert S: Detection of left atria1 thrombi by echocardiography. Br Heart d 45148. 1981. 13. Shrestha NK, Moreno FL, Narcisco FV, Torres L, Calleja HB: Two-dimensional echocardiographic diagnosis of left atria1 thrombus in rheumatic heart disease. Circulation 67~941, 198X 14. Furukawa K. Katsume H, Matsukubo H, Inoub D: Echocardiographic findings of fioat.in p thrombus in left atrium. Br Heart d 44:599. 1980. H. Hoshiai M, Furuya H, Kuribayashi S, Ootaki M, 15. Tomoda Matsuyama S, Koide S. Kawada S, Shotsu A: Evaluation of intracardiac thrombus with computed tomography. Am d Cardiol 5 1:843, 1983. 16. Tallwry MD, Depasquale NP: Ultrasound cardiography in the diagnosis of atria1 thrombus. Chest 59:501, 1971. 17. Spangler RD, Okin .JT: Echocardiographic demonstration of a left atria1 thrombus. Chest 67:716, 1975. 18. Denbow CE, Tajik AJ, Seward JB, Pluth JR: Massive thrombus in body of left atrium. Clinical profile and surgical experience (abst). Circulation 58(suppl II):Z32, 1978.
Constrictive pericarditis following myocardial revascularization: A possible cause of graft occlusion Sami S. Kabbani, M.D., Tali Bashour, M.D., David G. Ellertson, M.D., JamesGeiger, M.D., Elias S. Hanna, M.D. and Tsung 0. Cheng, M.D. San Francisco,
Calif., and Washington.
DC.
Constrictive pericarditis following aortocoronary bypass operations has infrequently been reported in the literature.‘-” Furthermore, only in one report’ was a form of pericarditis (the post pericardiotomy syndrome) incriminated in the production of graft occlusion. We describe here our experience with four patients who underwent aortocoronary bypass operations and developed an early post operative pericarditis resulting in graft occlusion in all four patients and myocardial constriction in three of these. The four patients were seenwithin a spanof 2 years and 3 months. During the sameperiod, 1158open-heart operations were carried out at our institution. The first patient, a 53-year-old man, wasfirst admitted to our hospital with inferior myocardial infarction. He remained asymptomatic for 10 years afterwards, then was readmitted with exertional angina. Cardiac catheterization revealed total occlusion of the right coronary (RC) artery and severe proximal stenosisof the left anterior descending (LAD) and circumflex (CX) arteries. The patient underwent aortocoronary bypassto the LAD and obtuse marginal (OM) branches.His postoperative course was marked by the appearanceof a pericardial rub and widened mediastinum 4 days after operation, and an echocardiogramwas suggestiveof the presenceof a large amount of anterior pericardial effusion. His jugular veins becamedistended and a 16 mm Hg pulsusparadoxus was detected. Serial roentgenograms of the chest revealed gradual resolution of effusion. Seven weeks after operation, the patient was readmitted with obvious manifestations of myocardial constriction. Right heart catheterization was consistent with constrictive pericarditis. At operation a desmoplasticreaction wasfound involving the anterior mediastinal tissues. The RC and OM grafts appearedengulfed in the thick pericardial peel. Decortication starting with the left ventricle was carried out, and the grafts were freed. The postoperative course was uneventful. The secondpatient, a %-year-old man, wasfirst admitted with a recent history of exertional angina. He had sustainedtwo myocardial infarctions 7 and 2 years prior to admission.Cardiac catheterization revealed severe occluFrom the Western Medical Center. Reprint Mary’s 9411;
requests: Hospital
Heart
Institute;
Tali T. Bashour, 6i Medical Center,
and
the Geor.re
Wwhington
M.D.. Western Heart 4.50 Stanvan St.. San
University Institute. Francisco.
St. CA