Ann Thorac Surg 2008;85:343. doi:10.1016/j.athoracsur.2007.03.054
© 2008 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Huge Right Atrial Thrombus 6 Years After Heart Transplantation
Ömer Sezer, MDa,*,
Henryk A. Welp, MDa,
Murat Özgün, MDa,
David Maintz, MDb,
Hans Heinrich Scheld, MDb,
Andreas Hoffmeier, MDa
a Department of Thoracic and Cardiovascular Surgery, University Hospital of Münster, Münster, Germany
b Institute of Radiology, University Hospital of Münster, Münster, Germany
* Address correspondence to Dr Sezer, Department of Thoracic and Cardiovascular Surgery, University Hospital Münster, Albert-Schweitzer-Str. 33, Münster, 48149, Germany (Email: oemer.sezer{at}ukmuenster.de).
We report on a 44-year-old man who suffered from end-stage heart failure due to dilated cardiomyopathy. Due to a low cardiac output situation, he was successfully bridged to cardiac transplantation for 180 days by the implantation of a left ventricular assist device. The operation was performed in the technique first described by Shumway and colleagues [1]. Post-transplantation medication included cyclosporine A, mycophenolate mofetil, and steroids for immunosuppression as well as acetyl salicylic acid for anticoagulation.
Six years after transplantation the patient was in excellent clinical condition. Routine myocardial biopsy and transthoracic echocardiography verified unremarkable transplant function.
Two months after switching immunosuppressive medication from cyclosporine to everolimus for progressive renal failure, a rapid deterioration of the patient’s clinical condition was observed. New York Heart Association class declined from class I to class III–IV. Echocardiography revealed no signs of rejection but showed a huge right atrial tumor mass measuring 5.5 cm in diameter. Electrocardiography showed sinus rhythm.
The dignity of the tumor mass was unclear, but native thoracic magnetic resonance imaging was strongly suggestive for thrombus formation (Fig 1, axial view; LA = left atrium; RA = right atrium; RV = right ventricle; LV = left ventricle; arrow: thrombus); (Fig 2, long axis view; RA = right atrium; arrow: thrombus). The tumor was resected using cardiopulmonary bypass (Fig 3). Intraoperative findings showed unremarkable atrial suture lines. No other irregularities of the atrial heart walls were observed. Histologic examination of the tumor mass confirmed the findings from magnetic resonance imaging.
The postoperative course was uneventful and the patient was discharged 9 days after the operation in good clinical condition and after therapy with phenprocoumon was initiated.
Although clotting disorders were not ruled out, the thrombus formation might be related to the enlargement of the right atrium (8.6 x 5.8 cm). As a consequence from the reduction in blood flow velocity, the coagulation cascade might have been activated. An increased risk of thrombus formation under immunosuppressive treatment with everolimus has not been reported in literature so far, but it can not be ruled out completely as a cause for the thrombus in this case.
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References
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- Shumway NE, Lower R, Stofer RC. Transplantation of the heart Adv Surg 1966;2:265-284.[Medline]
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