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Ann Thorac Surg 2006;82:1538
© 2006 The Society of Thoracic Surgeons

Images in Cardiothoracic Surgery

Large Tricuspid Mass in Primary Antiphospholipid Syndrome

Olatunde Falode, MRCS, Ian Hunt, MRCS*, John Chambers, MD, FACC, Christopher Blauth, FRCS

Departments of Cardiothoracic Surgery and Cardiology, St. Thomas' Hospital, London, United Kingdom

* Address correspondence to Dr Hunt, Cardiothoracic Surgery Centre, St. Thomas' Hospital, London, SE1 7EH United Kingdom (Email: ian.hunt{at}gstt.nhs.uk).

A 35-year-old woman was admitted with a 2-year history of progressively worsening exertional breathlessness. Based on clinical and serological evidence she had a known primary antiphospholipid syndrome and was presently on warfarin. She had no history of intravenous drug abuse. Echocardiography showed massive vegetations involving the tricuspid valve, filling the right atrium and causing severe tricuspid stenosis. There was no regurgitation. The right ventricle was dilated, but it had good free wall function (Fig 1) (arrows = tricuspid mass; LV = left ventricle; RA = right atrium; RV = right ventricle).


Figure 1
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  		Fig 1.
 
At surgery on opening the right atrium, the mass was identified and removed with debridement of the lower right atrial wall (Fig 2, as seen from the surgeon's perspective). Further removal of the mass around the ostium of the inferior vena cava was also carried out. The tricuspid valve was structurally normal, but it was involved, and therefore it was replaced. Postoperatively the patient required a permanent pacemaker for complete heart block; otherwise she made an uneventful recovery and remains well at 3 months. Histology demonstrated loose fibrous tissue with massive dystrophic calcification (Fig 3). Giant cells were present, but no significant inflammation in the noncalcified tissue was seen.


Figure 2
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  		Fig 2.
 

Figure 3
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  		Fig 3.
 
Involvement of cardiac valves in primary antiphospholipid syndrome is recognized and typically involves the mitral and aortic valves [1]. Tricuspid valve lesions in primary antiphospholipid syndrome have been rarely reported [2, 3]. The primary antiphospholipid syndrome valvular lesion consists mainly of fibrin deposits and its subsequent organization with vascular proliferation, fibrosis, and calcification. This results in valvular thickening, fusion, and rigidity leading to functional abnormalities [1]. As in this case, inflammation is not a prominent feature in this lesion.


   References
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 References
 

  1. Garcia-Torres R, Amigo MC, de la Rosa A, Moron A, Reyes PA. Valvular heart disease in primary antiphospholipid syndrome (PAPS): clinical and morphological findings Lupus 1996;5:56-61.[Medline]
  2. Turjanski AA, Finkielman JD, Vazquez-Blanco M. Isolated tricuspid valve disease in antiphospholipid syndrome Lupus 1999;8:474-476.[Abstract/Free Full Text]
  3. Yoong JK, Jaufeerally FR. Isolated tricuspid valve vegetations and steno-insufficiency in primary antiphospholipid syndrome Singapore Med J 2004;45:127-129.[Medline]



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The antiphospholipid syndrome and heart valve surgery
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[Abstract] [Full Text] [PDF]

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