Ann Thorac Surg 2005;80:1498-1500
© 2005 The Society of Thoracic Surgeons
Case report
A Rare Presentation of Tricuspid Valve Thrombus in a Normal Heart
Pankaj Saxena, MCh
*
,
Ross Mejia, MBBS,
Robert K.W. Tam, FRACS
Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, Brisbane, Australia
Accepted for publication April 5, 2004.
* Address reprint requests to Dr Saxena, Department of Cardiac Surgery, The Prince Charles Hospital, Rode Rd, Chermside, Brisbane QLD 4032, Australia (Email: drpankajsaxena{at}hotmail.com).
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Abstract
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A young woman presented with a presumptive diagnosis of tricuspid valve tumor in a structurally normal heart. She was recently started on oral progesterone for menorrhagia related to uterine fibroids. She underwent an excision of the mass attached to the tricuspid valve, which was found to be an organized thrombus. We suggest a clinical approach to this problem.
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Introduction
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Tricuspid valve thrombus can mimic cardiac tumor. This condition can occur in a structurally normal heart without a hypercoagulable state. It is important to investigate these patients extensively to rule out contributory factors.
A 33-year-old woman presented to her general practitioner with a history of shortness of breath, chest pain, and swelling of the feet in June 2002. One month later she started having menorrhagia and was started on oral iron therapy for anemia. She was a nonsmoker. Her general and systemic examination was normal except for a palpable uterus. There was no history of deep vein thrombosis, trauma, or use of intravenous drugs. As she continued to have cardiopulmonary symptoms, she was investigated with duplex ultrasound of the lower limbs, ultrasound of the pelvis, and a spiral computerized tomographic scan of the pulmonary arteries. An exercise treadmill test was negative for myocardial ischemia. She was found to have multiple fibroids in her uterus. Also a transthoracic and transesophageal echocardiogram showed the presence of a mass of 1.2 x 2.3 cm size attached to the septal leaflet of the tricuspid valve (Fig 1). There was tricuspid regurgitation, which was graded as 1 to 2/4. There was some evidence of pulmonary hypertension. Right ventricular systolic pressure was raised to 48 mm Hg. A diagnosis of papillary fibroelastoma was made by the appearance of the echocardiogram.
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Fig 1. Preoperative transesophageal echocardiogram showing the thrombus attached to the septal leaflet of the tricuspid valve. (RA = right atrium; RV = right ventricle.)
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She needed blood transfusions for anemia; her hemoglobin was 73g. She was started on oral progesterone for menstrual abnormality. Her complete blood count, prothrombin time, activated partial thromboplastin time, fibrinogen levels, proteins C and S, and antithrombin were found to be normal. The 5-hydroxy indole acetic acid (5-HIAA) was absent in urine. Factor V Leiden, antinuclear antibodies, and anticardiolipin were not detected.
A month before undergoing cardiac surgery, progesterone was replaced with an intranasal gonadotrophin release hormone analogue. She underwent excision of the mass lesion using cardiopulmonary bypass. There was a 2 x 1 cm noninvasive tumor found attached to a chord of septal leaflet of tricuspid valve. There was no other abnormality of the tricuspid valve or the right side of the heart. The chord bearing the tumor was excised and repaired with a 4-0 Gore-Tex suture (W.L. Gore and Assoc, Flagstaff, AZ). The patient made an uneventful recovery after the operation. A postoperative echocardiogram revealed grade 1/4 tricuspid regurgitation. Histopathology showed the presence of an organized thrombus of the chord (Fig 2). The gram stain of the excised valve tissue and blood cultures did not show any bacterial infection. The patient was discharged home on warfarin for 6 months. She was referred to the gynecologist for surgical treatment of fibroids of the uterus.
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Comment
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A tricuspid valve mass is most likely a tumor or vegetation. Papillary fibroelastomas are usually attached to the valve leaflets and are the third most common type of primary cardiac tumors [1, 2].
Development of the thrombus on the tricuspid valve is a rare problem. It usually mimics infective endocarditis or tumor. An abnormality of coagulation factors can promote thrombus formation on tricuspid valves in the neonate [3]. Tricuspid valve thrombus can be mistaken preoperatively for myxoma [4]. Multiple thrombi can occur on the tricuspid valve leaflet in an infant with a structurally normal heart without sepsis, coagulation abnormality, or the presence of indwelling intravenous catheter [5]. Konishi and colleagues [6] described a 23-year-old woman who was found to have an organized tricuspid valve thrombus attached to the septal leaflet of the tricuspid valve. This was associated with the presence of a pouch of the tricuspid valve and a ventricular septal defect. The authors attributed the development of thrombus to stagnation of blood resulting from a pouch of the tricuspid valve and a ventricular septal defect.
The present case report describes diagnosis of tricuspid valve thrombus in a structurally normal heart. We offer two probable explanations for the development of the thrombus in such an unusual location. The first possibility is the entrapment of pulmonary emboli in the tricuspid valve from deep vein system or pelvic veins. The second possibility is the secondary development of thrombus on the valve from minor endothelial injury or stasis of blood in the right side of the heart from pulmonary hypertension [7], which was probably caused by recurrent pulmonary emboli. The patient had begun progesterone at the time of her cardiac diagnosis. Uterine fibroids and progesterone may have contributed to the thrombus formation and propagation. We believe that her symptoms were partly due to pulmonary thromboembolism arising from lower limb or pelvic veins. These were probably lysed by the natural fibrinolytic system. Residual thrombus was left on the tricuspid valve. It is not always easy to make a diagnosis of deep vein thrombosis or pulmonary thromboembolism. Natural fibrinolysis plays an important role in the dissolution of these thrombi emboli [8]. The magnetic resonance imaging scan has been found to be more sensitive and specific for detection of thrombi in deep veins of the lower limbs and pelvic veins [9]. We justify our approach of using the computerized tomographic scan and duplex ultrasound of the lower limbs as one of the most cost effective approaches for suspected diagnosis of pulmonary thromboembolism. The echocardiographic appearance was suggestive of papillary fibroelastoma; hence no further investigations were carried out.
We recommend a magnetic resonance imaging scan of the lower limb and pelvic veins in a patient who presents with a pelvic tumor right heart mass with or without a procoagulant state. Surgical exploration and excision is indicated to rule out the diagnosis of tumor and prevent the occurrence of embolic complications.
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References
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- Özkutlu S, Saraçlar M, Atalay S, Demircin M, Ruacan S. Two-dimensional echocardiographic diagnosis of tricuspid valve noninfective endocarditis due to protein C deficiency (lesion mimicking tricuspid valve myxoma) Jpn Heart J 1991;32(1):139-145.[Medline]
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- Moser KM, Guisan M, Bartimmo EE, Longo AM, Harsanyi PG, Chiorazzi N. In vivo and postmortem dissolution rates of pulmonary emboli and venous thrombi in the dog Circulation 1973;48:170-178.[Abstract/Free Full Text]
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Abstract
Introduction
