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Ann Thorac Surg 2007;84:1742-1744. doi:10.1016/j.athoracsur.2007.05.065
© 2007 The Society of Thoracic Surgeons
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Case Reports

Right Atrial Mass After Primary Repair of an Atrial Septal Defect: Thrombus Masquerading as a Myxoma

Ahmad Y. Sheikh, MDa, Sonja Schrepfer, MDa, William Stein, MDa, Joan West, PAb, Jane Lombard, MDc, Tom Burdon, MDa, Bob Pinsker, MDd, Marc P. Pelletier, MD, MSa,b,*

a Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
b Department of Cardiothoracic Surgery, El Camino Hospital, Mountain View, California
c Department of Cardiovascular Disease, El Camino Hospital, Mountain View, California
d Department of Anesthesiology, El Camino Hospital, Mountain View, California

Accepted for publication May 29, 2007.

* Address correspondence to Dr Pelletier, Department of Cardiothoracic Surgery, Stanford University Medical Center, 300 Pasteur Dr, Falk CVRB, Stanford, CA 94305 (Email: marcp{at}stanford.edu).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Atrial septal defects are among the most common congenital anomalies requiring surgical repair. Thrombus formation after patch-based repair is a recognized complication, usually manifested by an embolic event. However, thromboembolic complications after primary repair of atrial septal defects are exceedingly rare. We present a 38-year-old woman found to have a right atrial mass diagnosed as a myxoma by echocardiography and magnetic resonance imaging 3 years after primary atrial septal defect repair. However, final pathology revealed an organized thrombus. A review of the literature and clinical management of postoperative atrial thrombi are discussed.


   Introduction
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 Abstract
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 References
 
It is well recognized that both device and surgical patch-based repairs of adult atrial septal defects (ASDs) may result in acute thromboembolic complications [1, 2]. However, formation of chronic thrombus after primary suture repair of ASDs and patent foramen ovale (PFO) is exceedingly rare, and there are limited data detailing such complications. We present a rare case of silent thrombus after primary ASD, initially diagnosed as a myxoma.

A previously healthy 35-year-old Asian woman underwent primary repair of a secundum type ASD without complication. Three years postoperatively, although she remained asymptomatic, a routine follow-up echocardiography demonstrated a round, pedunculated, right atrial mass with a stalk and characteristics suggestive of a myxoma (Fig 1). Further imaging of the mass by preoperative magnetic resonance imaging and transesophageal echocardiography was also highly consistent with an atrial myxoma (Fig 2).


Figure 1
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  		Fig 1. Noninvasive, dual-modality imaging of the right atrial mass. Series of images from a transesophageal echocardiographic study revealing a mass in the right atrium: (i) two-chamber view with mass indicated by arrow, (ii) four-chamber view with mass indicated by arrow, and (iii) corresponding Doppler image demonstrating blood flow (blue) through tricuspid valve without obstruction by the mass (arrow).

 

Figure 2
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  		Fig 2. Four-chamber magnetic resonance imaging view of the heart with pedunculated mass in the right atrium. Arrow demonstrates stalk attaching mass to posterior atrial wall.

 
The patient underwent redo sternotomy and resection of the mass. Exploration of the right atrium revealed a 2.1 x 2.3 cm globular mass, with a tan, gelatinous appearance and multifocal areas of calcification. The mass was attached to the posterior wall of the right atrium by a 1-cm stalk, and it was excised along with a small rim of surrounding atrial wall. The residual atrial wall defect was closed primarily with 4-0 Prolene (Ethicon, Somerville, NJ). Inspection of the right atrium revealed two visible, endothelized Prolene sutures (Ethicon) located 1 to 2 cm away from the mass, with otherwise normal anatomy.

Histology revealed the mass to be an organized thrombus (Fig 3). The patient had an uneventful postoperative course and was discharged home on postoperative day 5. A postoperative hypercoagulability screening panel was negative. The patient was started on both aspirin (81 mg/day) and warfarin to maintain a 2 to 3 international normalized ratio for 3 months. The postoperative echocardiogram at 3 months was normal.


Figure 3
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  		Fig 3. Surgical resection and pathologic evaluation of specimen: (A) right atrial wall retracted to reveal thrombus in situa. (B) Gross specimen with pedunculated stalk (arrow). (C) Hematoxylin and eosin stain of specimen at 40x magnification. Tissue consists of fibrin-platelet thrombotic material with dystrophic calcification. The typical rings and nests of cells that emanate from vascular structures and the myxoid stroma that is characteristic of cardiac myxoma are absent. (D) Hematoxylin and eosin stain of specimen at 200x magnification with dystrophic calcification marked by arrows.

 

   Comment
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References
 
Presently we believe that there are only two reports in the English literature that describe thromboembolic complications after primary ASD or PFO repair, in which both patients presented with embolic symptoms. Rodriguez and colleagues [3] described a patient with recurrent neurologic and peripheral embolic events approximately 6 months after primary repair of a PFO [3]. More recently, Dinckal and colleagues [4] reported a 53-year-old patient who presented with multiple pulmonary emboli 3 months after primary repair of ASD [4]. In both cases, the suture line served as the nidus for thrombus formation, and both patients presented with embolic events almost immediately after surgery. The present case is unique in that the patient was asymptomatic when the atrial thrombus was fortuitously discovered by transthoracic echocardiography 3 years after her initial repair.

Given the rarity of thrombus formation after primary ASD repair, coupled with the patient’s longstanding asymptomatic postoperative course, further imaging was obtained by transesophageal echocardiography and magnetic resonance imaging. Both modalities suggested the more common diagnosis of an atrial myxoma. Myxomas remain the most common cause of atrial tumors and are often discovered incidentally, as was the mass in our patient [5]. Moreover, given the reported rapid rates of the growth of a myxoma after surgical intervention (eg, development of a 4 x 6 cm myxoma within 8 months), development of an approximately 2-cm2 mass between interval echocardiograms seemed a reasonable possibility [6].

The case highlights the importance of considering the possibility of thrombus long after primary repairs of the ASD. Furthermore, the workup revealed limitations of current imaging modalities to discern between organized clot and atrial myxoma. Although acoustic density has been used to distinguish between thrombus and myxoma [5], such evaluation did not help in this case. Cardiac computed tomography might have provided more detailed information, but was not performed given the low index of suspicion for thrombus and unequivocal findings by echocardiography and magnetic resonance imaging.

If preoperative tissue diagnosis had been possible, alternative treatment options for atrial thrombus including thrombolysis, anticoagulation, and catheter-based retrieval might also have been considered. Catheter-based retrieval is a relatively novel development, with a limited number of case reports describing this approach [7, 8]. Recent data from meta-analyses and Dinckal and colleagues’ [4] case report support the use of thrombolytics and anticoagulation therapy [4, 8]. However, a well-controlled trial evaluating these approaches against the open surgical approach remains to be conducted. It should also be pointed out that the majority of data evaluating treatment of atrial thrombus come from patients suffering from large embolized clot loads from deep venous thrombosis (ie, "emboli in transit") or transmural thrombi generated secondary to turbulent atrial flow states (eg, atrial fibrillation). Whether these techniques can be used for postoperative thrombi is unclear. This consideration is especially apt, as the nature of a developing thrombus at a suture line might be more or less resistant to anticoagulation therapy compared with a relatively fresh, embolized thrombus caught in the atrium. This point is well illustrated in this case, whereupon intraoperative examination, the thrombus was found to be a well formed, hard mass with a reasonable pedicle attaching it to the atrial wall. The hard consistency and histologic appearance of the thrombus suggested that a response to lytic or anticoagulation therapy would be highly unlikely.

One final aspect of this case involves the appropriateness of anticoagulation therapy after primary ASD repair. For catheter-based therapy and patch repair of ASDs, patients are routinely anticoagulated until endothelialization of the foreign material is believed to be complete (ie, typically 3 months). However, in the case of primary repairs of PFOs or ASDs, most centers refrain from postoperative anticoagulation. Given the findings from this case and the others discussed, such anticoagulation strategies may deserve review.

For future cases of primary ASD repair, it may be prudent to anticoagulate patients for approximately 3 months, as has been previously suggested [4]. Also this case illustrates the importance of early echocardiography follow-up after intracardiac repair. This approach may help to identify postoperative thrombi earlier, providing a therapeutic window for anticoagulation or lytic therapy. A combination of preoperative hypercoagulability screening, postoperative anticoagulation, and routine interval assessment by echocardiography may provide the optimal strategy.

In conclusion, thrombus formation at the site of primary ASD or PFO repair is an uncommon postoperative complication that has the potential for embolic sequelae. The present case demonstrates the importance of postoperative interval imaging to detect potential thrombi prior to manifestation by embolic event. A short course of routine postoperative anticoagulation might also be considered in patients undergoing primary ASD repair.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Chessa M, Carminati M, Butera G, et al. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect J Am Coll Cardiol 2002;39:1061-1065.[Abstract/Free Full Text]
  2. Hawe A, Rastelli GC, Brandenburg RO, McGoon DC. Embolic complications following repair of atrial septal defects Circulation 1969;39(5 Suppl 1):I185-I191.[Medline]
  3. Rodriguez CJ, Di Tullio MR, Sacco RL, Homma S. Intra-atrial thrombus after surgical closure of patent foramen ovale J Am Soc Echocardiogr 2001;14:63-66.[Medline]
  4. Dinckal MH, Davutoglu V, Soydinc S, Akdemir I, Aksoy M. Large thrombus at the site of primary sutured atrial septal defect associated with pulmonary embolism and treatment by thrombolysis Echocardiography 2003;20:535-538.[Medline]
  5. Markel ML, Waller BF, Armstrong WF. Cardiac myxomaA review. Medicine (Baltimore) 1987;66:114-125.[Medline]
  6. Roudaut R, Gosse P, Dallocchio M. Rapid growth of a left atrial myxoma shown by echocardiography Br Heart J 1987;58:413-416.[Abstract/Free Full Text]
  7. Davies RP, Harding J, Hassam R. Percutaneous retrieval of a right atrioventricular embolus Cardiovasc Intervent Radiol 1998;21:433-435.[Medline]
  8. Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli Chest 2002;121:806-814.[Medline]



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 Ann. Thorac. Surg.Home page
A. Y. Sheikh and M. P. Pelletier
Reply
Ann. Thorac. Surg., June 1, 2008; 85(6): 2162 - 2163.
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