Abstract 19335: Not Your Typical Atrial Flutter

Abstract

Case: Mr M. presented to the emergency room with two months of progressive shortness of breath and was found to be in atrial flutter with 2:1 conduction at a rate of 140 bpm. His medical history was significant for tobacco use, etoh abuse, and hypertension. Key objective findings included tachycardia, hypoxia an elevated JVP, bibasilar crackles, a summation gallop, and lower extremity edema. His work up included an echocardiogram that illustrated a globally depressed EF (15-20%) and a large “worm like” mass that was free floating and extended into the RV. Management: A heparin drip was already infusing as the initial plan included cardioversion. Since the patient remained hemodynamically stable and there was no evidence of concurrent deep vein thrombosis, a TEE was performed to fully evaluate the mass and to assess the intra-atrial septum for right to left shunting. The TEE with 3D renderings demonstrated a mobile 0.8 x 10 cm mass most consistent with a thrombus that intermittently prolapses through the tricuspid valve into the RV. CT surgery was consulted and discussed the options of thrombolysis vs surgical thrombectomy. Due to the size and apparent dense organization of the thrombus, surgical thrombectomy was performed. When the right atrium was opened after initiation of bypass, there was no visible clot. The main PA was explored and without evidence of the thrombus. As bypass flow decelerated, the clot proceeded into the RA from the IVC cannula. The attached picture illustrates the thrombus removed from the RA and associated echo images. Discussion: Right atrial or ventricular thrombi in transit in hypoxic patients create a challenging clinical dilemma, as distal embolization may be fatal. In this case we chose to surgically remove the thrombus instead of the more commonly employed thrombolytic therapy. The determining factors included clot organization, relative patient stability, and surgical candidacy.