Ann Thorac Surg 1996;62:1505-1506
© 1996 The Society of Thoracic Surgeons
Case Report
Right Atrial Mural Thrombus Associated With Pericarditis
Riichiro Toda, MD,
Toshiyuki Yuda, MD,
Takuji Nishida, MD,
Hitoshi Toyohira, MD,
Akira Taira, MD
Second Department of Surgery, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
Accepted for publication April 24, 1996.
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Abstract
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A 33-year-old man was hospitalized with right heart failure. He was diagnosed as having right atrial mural thrombus complicated with pericarditis on echocardiography, thoracic computed tomography, and cardiac catheterization. Pericardiectomy and thrombectomy with a partial resection of the right atrial wall were performed under extracorporeal circulation. It was suggested that the cause of right atrial thrombus was congestion, atrial fibrillation, and pericarditis. The cause of pericarditis could not be determined by pathologic examination and laboratory data. Surgical treatment should be performed as soon as possible to prevent pulmonary embolism.
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Introduction
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Right atrial thrombus associated with pericarditis is very rare. We experienced a case of right atrial mural thrombus associated with pericarditis. Here we describe the cause of the thrombus and recommend surgical therapy to prevent pulmonary embolism.
A 33-year-old man had been suffering from atrial fibrillation, generalized edema, and fatigue for 10 years when he underwent an emergency pericardiocentesis and drainage for cardiac tamponade on a journey to Hawaii 6 months ago. He was hospitalized with exertional dyspnea and abdominal distention at Miyazaki Prefectural Hospital on April 12, 1995.
Chest roentgenography revealed mild cardiac enlargement (cardiothoracic ratio, 0.58). Atrial fibrillation was noted on the electrocardiogram. Thoracic computed tomography showed a low-density mass about 2.5 cm in diameter in the right atrium, and a thickened pericardium. Transesophageal echocardiography showed a mosaic pattern mass in the right atrium. A dip and plateau pattern was seen on the right ventricular pressure tracing on cardiac catheterization. Pulmonary arterial diastolic pressure, right ventricular end-diastolic pressure, and right atrial mean pressure were 29, 20, and 20 mm Hg, respectively. Accordingly, we diagnosed right heart failure due to constrictive pericarditis and complicated with a right atrial tumor.
Pericardiectomy and removal of the tumor with a part of the right atrial wall were performed under extracorporeal circulation. Dissection between the pericardium and the cardiac wall was easy because there was little calcification on the pericardium. Next, the thick right atrium was opened under extracorporeal circulation. The tumor sticking to the thick right atrial wall was removed with a part of the right atrial wall. The tumor was mural thrombus by pathologic examination. Pathologic findings of removed right atrial wall showed myocardial hypertrophy and wave formation. The postoperative course was satisfactory, and the patient was discharged on the 30th postoperative day.
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Comment
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Right atrial thrombus associated with pericarditis is very rare. Only 5 cases have been reported in the world literature [1–5]. Thrombus in the heart is ordinarily produced in the left atrium or ventricle; thrombus in the right atrium or ventricle is very rare. Wartman and Hellerstein [6] reported that right atrial thrombus was detected in 14 of more than 2,000 autopsied cases. Felner and associates [7] reported 11 cases of right atrial thrombus that were associated with dilated cardiomyopathy or heart failure. It is thought that the causes of thrombus production result from stagnation of the bloodstream, injury of the intima, and hypercoagulopathy [1, 5]. We concluded that the cause of thrombus was congestion in the right atrium associated with atrial fibrillation and pericardial effusion or pericarditis. It was suggested that inflammation might extend to the right atrium. The cause of pericarditis was neither tuberculosis nor malignant disease by pathologic examination. It has not been clarified.
It is important to distinguish thrombus from tumor. Transesophageal echocardiography [8], thoracic computed tomography, and magnetic resonance imaging [5] may be effective to make the differential diagnosis, but we could not definitely differentiate thrombus from tumor by thoracic computed tomography and transesophageal echocardiography. Surgical treatment should be made as soon as possible to prevent pulmonary embolism and to make the differential diagnosis. During operation also much care should be taken to prevent the release of thrombus from the right atrial wall under extracorporeal circulation. Fortunately, release of thrombus did not occur in this case because the thrombus adhered tightly to the right atrial wall.
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Footnotes
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Address reprint requests to Dr Toda, Second Department of Surgery, Faculty of Medicine, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima city, 890, Japan.
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References
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- Akiyama K, Nakae S, Imamura E, Endo M, Hayashi H, Koyanagi H. A case of right atrial thrombus associated with constrictive pericarditis. Rinshou Kyoubu Geka 1984;4:607–12.
- Tanabe Y, Matsuoka A, Obata A, et al. Tuberculous constrictive pericarditis complicated with right atrial thrombus. Shinzo 1989;21:1158–63.
- Fujimura M, Ryujin Y, Ito S, et al. A surgical case of right atrial giant thrombus associated with diffuse pericardial calcification and with an onset of multiple pulmonary infarction. Nippon Kyobu Shikkan Gakkai Zasshi 1986;24:541–6.[Medline]
- Nishimura T, Misawa T, Park YD, Uehara T, Hayashida K, Hayashi M. Visualization of right atrial thrombus associated with constrictive pericarditis by indium-111 oxine platelet imaging. J Nucl Med 1987;28:1344–7.[Abstract/Free Full Text]
- Yoshida M, Kawaraya N, Ota T, Okada M. A case of right atrial thrombus associated with idiopathic pericarditis. J Jpn Assoc Thorac Surg 1994;42:2155–8.
- Wartman WB, Hellerstein HK. The incidence of heart disease in 2,000 consecutive autopsies. Ann Intern Med 1948;28:41–65.[Medline]
- Felner JM, Churchwell AL, Murphy DA. Right atrial thromboemboli. Clinical echocardiographic and pathophysiologic manifestations. J Am Coll Cardiol 1984;4:1041–51.[Medline]
- Alam M, Sun I, Smith S. Transesophageal echocardiographic evaluation of right atrial mass lesions. J Am Soc Echo 1991;4:331–7.[Medline]
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Abstract
Introduction
