Right Atrial Thrombus Research Articles

Right Atrial Thrombus Masquerading as Myxoma.

In-situ right atrial (RA) thrombus is a rare occurrence typically associated with heightened inflammatory or hypercoagulable states. Here, we present a case of in-situ RA thrombus mimicking atrial myxoma in a patient with sepsis and bacteraemia. A 41-year-old man presented with septic arthritis and bacteraemia caused by methicillin-resistant Staphylococcus aureus (MRSA). A transoesophageal echocardiogram revealed a large pediculated mass resembling atrial myxoma, which was not visible on transthoracic echocardiography performed four days earlier. Cardiac magnetic resonance (CMR) imaging strongly suggested a thrombus, leading to the patient undergoing transcatheter aspiration. Subsequent pathology confirmed an organised fibrin thrombus without evidence of infection. The patient's in-situ RA thrombus likely developed in response to a heightened inflammatory state associated with sepsis. Limited data exist on in-situ RA thrombi in the absence of atrial fibrillation, though some reports suggest a correlation between heightened inflammation and a hypercoagulable state. CMR imaging is invaluable for characterising such masses and can aid in distinguishing a thrombus from a myxoma. Differentiating right atrial (RA) thrombus from myxoma: cardiac magnetic resonance imaging is essential for distinguishing RA thrombus from myxoma, preventing unnecessary surgeries.Hypercoagulable and inflammatory states: spontaneous in-situ RA thrombi can occur without deep vein thrombosis (DVT) or atrial fibrillation, especially in hypercoagulable and inflammatory conditions.Transcatheter aspiration: this less invasive alternative to surgery is effective for large, mobile RA thrombi, reducing embolisation risk.

Abstract 15294: Right Atrial Thrombus Extraction Through Angiovac - A Challenge Based on Chronicity

Case Presentation: 23-year-old woman with right ovarian dysgerminoma, treated with debulking surgery and bleomycin, etoposide, and platinum, found to have a right atrial (RA) mass on post-chemotherapy surveillance CT and referred to the cardiology clinic. Her vitals were stable, lungs were clear to auscultation, RRR without murmurs, no JVD or LE edema. On labs, hgb:11g/dL and LDH:283 units/L(135 to 214 units/L). A transthoracic echocardiogram (TTE) and a cardiac MRI revealed a mass of RA at the junction of inferior vena cava (IVC) entry into RA, measuring 3x1.3 cm in the 2-chamber view and 2.4x1.8 cm in the 4-chamber view (Fig A,B) with prolapse into the right ventricle (RV) in diastole. Based on cardiac MRI’s short and long inversion time imaging characteristics, thrombus was the most likely diagnosis (Fig C). Shared decision-making with the patient included options: 1) open heart surgery for removal; 2) interventional aspiration thrombectomy; or 3) conservative treatment with anticoagulation (AC). After six weeks of AC with enoxaparin, TTE revealed a RA thrombus of the same size as previously (2.8x1.2 cm). Given the lack of improvement, she agreed to an invasive procedure to remove the mass using an AngioVac aspiration system (AngioDynamics, Latham, NY). The AngioVac cannula maneuvered in the RA under fluoroscopic and TEE guidance to capture the RA mass. However, the mass broke into two pieces, one piece still attached to the RA and the other piece lodged in the AngioVac cannula (Fig D,E). She remained hemodynamically stable after the procedure. The pathology of the RA mass revealed an organized thrombus (Fig F). She had no complaints on follow-up in the clinic and continued on AC for 6 months. Discussion: Percutaneous aspiration thrombectomy using the AngioVac system has become a novel option for removing commonly encountered intravascular material, such as fresh thrombi or emboli in the RA, RV, SVA, IVC, and the iliofemoral vein, but may be complicated in old thrombi.

AngioVac Aspiration Thrombectomy of Right Atrial Thrombus is Safe and Effective in Cancer Patients

The aim of this study was to test the hypothesis that endovascular aspiration thrombectomy of right atrial thrombus (RAT) using the AngioVac device is as safe and effective in patients with cancer as those without cancer. RAT is a uniquely challenging clinical presentation of venous thromboembolism due to its low incidence and historically high-risk of mortality due to thrombus propagation into the pulmonary arteries. There is a lack of consensus regarding management, particularly in high-risk cancer patients. Endovascular aspiration thrombectomy utilizing the AngioVac device is effective in removal of right atrial thrombus and may be a safer option for patients with cancer in whom avoidance of higher-risk intervention is preferred. This was an institutional review board-approved retrospective single-center case control study of patients with RAT who underwent AngioVac aspiration thrombectomy between August 2013 and July 2020. Analysis of patient demographics and clinical characteristics, thrombus-related factors, and operative details was performed. Primary endpoints included survival, safety, and technical success. A total of 44 patients met inclusion criteria, 20 of whom with active malignancy. The oncology group had a significantly higher Charlson comorbidity index (P=0.01). Comparative outcomes between the oncology and non-oncology group showed no difference in survival (P=0.8) or technical success (OR 3, 95% CI 0.83-10.9). There were 9 complications, including 6 minor, 1 moderate, 1 severe, and 1 death. AngioVac aspiration thrombectomy of RAT is as safe and effective in patients with cancer as those without cancer.

Incidence of catheter-associated right atrial thrombus detected by transthoracic echocardiogram.

The development of right atrial (RA) thrombus (RAT) is a known complication of central venous catheter insertion (CVC). Deeper insertion of CVC within the RA may increase the risk for RAT development versus those placed at the superior vena cava (SVC)-RA junction. We sought to evaluate the incidence of catheter-associated RAT as detected by transthoracic echocardiograms (TTEs), characterize thrombi though multimodal imaging, and evaluate thrombi management with follow-up imaging. A retrospective analysis was conducted of consecutive TTEs from our institution between October 1, 2018, and January 1, 2020, in which a venous catheter was visualized in the RA. Studies were reviewed in detail to determine the presence of suspected RAT. Demographic data, comorbidities, laboratory values, characteristics of the catheter and the thrombus, subsequent imaging and management, and outcomes were collected. A total of 364 TTEs were performed in 290 patients with a venous catheter visualized in the RA. Of these 290 patients, 15 had an imaging suspicion for RAT yielding an incidence of 5.2%. Management strategies included anticoagulation in 13 (86.7%) patients and catheter removal in 11 (73.3%) patients. At eight months of follow-up, 11 (73.3%) patients had resolution of RAT based on subsequent imaging. In patients with deeply placed CVC catheters, the incidental detection of RAT by TTE was not trivial. Anticoagulation and catheter removal and replacement, if deemed safe, were effective methods of thrombus management. RAT as a complication of CVCs must be accounted for when addressing factors that influence depth of CVC insertion.

RIGHT ATRIAL THROMBUS MASQUERADING AS A MYXOMA. SYNERGISTIC EFFECTS OF HORMONAL CONTRACEPTIVES AND ANTI-PHOSPHOLIPID ANTIBODIES

Right atrial (RA) thrombi are uncommon and usually present as a complication of central venous catheter placement. RA thrombus secondary to oral contraceptives (OCP) or anti-phospholipid antibody syndrome (APS) has never been reported. A 24 year old female on OCP and history of mitral valve

Diagnostic utility and clinical implication of late gadolinium enhancement cardiac magnetic resonance for detection of catheter associated right atrial thrombus

PurposeTo use delayed enhancement cardiac magnetic resonance (DE-CMR) as a reference standard to evaluate the prevalence and predictors of right atrial (RA) thrombus. MethodsIn this retrospective study, 130 cancer patients with central venous catheters undergoing CMR from August 2012–January 2018 were included. CMR (cine-CMR and DE-CMR) and echocardiography were interpreted for RA thrombus blinded to other imaging results and clinical data. RA thrombus properties including the number of discrete masses, size, total thrombus area, and perimeter were also assessed. Cine-CMR was also used to quantify cardiac structure and function as markers of RA thrombus. Student's t-test was used to assess continuous variables; chi-square or Fisher's exact test were used to assess categorical variables. Results31/130 (24%) patients had RA thrombus on DE-CMR. Echocardiography (attained in 64% of the study population) demonstrated moderate sensitivity and specificity (75%, 90% respectively) in relation to DE-CMR; cine-CMR performance was higher (sensitivity 90%, specificity 98%). Patients with and without RA thrombus had similar right-sided structure/function and cancer diagnosis. Catheter depth approached significance in patients with RA thrombus (p = 0.05). 13% of patients with RA thrombus had concomitant pulmonary embolism within 60 days of CMR vs. 2% of patients without RA thrombus (p = 0.03). Embolic events were independent of RA thrombus size (p = 0.66). ConclusionMorphologic imaging by cine-CMR and echocardiography provide limited diagnostic utility for RA thrombus as established by DE-CMR tissue characterization. Catheter-associated RA thrombus occurs independently of right-sided structure or function and is associated with clinical embolic events and catheter depth.

A Case Series of Asymptomatic Hemodialysis Catheter-Related Right Atrial Thrombi That Are Incidentally Detected Prior to Kidney Transplantation

A hemodialysis (HD) catheter-related right atrial thrombus (RAT) is rarely encountered prior to kidney transplantation (KT) but necessitates a decision about whether to anticoagulate and/or delay the surgery. There is controversy surrounding the clinical implications of a RAT in this situation. It is sometimes considered fatal but other opinions consider it to be benign, especially when incidentally detected. We reviewed the clinical characteristics, management, and outcomes of a patient series with HD catheter-related RAT detected prior to KT and speculated on its clinical significance. Among 3677 cases of KT performed on 3607 patients between January 1997 and September 2015 in our single tertiary center, 11 cases of HD catheter-related RAT detected on transthoracic echocardiography (TTE) prior to KT were included for analysis. The average maximal diameter of the RAT was 23.2 ± 16.3 (SD in mm) and 9 (81.8%) of these 11 patients had no symptoms associated with the RAT. Four patients (36.3%) had their catheters replaced, 5 patients (45.5%) had their catheters removed, and the catheters were maintained in the remaining 2 patients (18.2%). Six patients (54.5%) were anticoagulated with either heparin or warfarin. However all 11 patients had a successful KT suggesting that a HD catheter-related RAT incidentally detected prior to this surgery may not be as serious as previously considered and should not be a reason for delaying the transplantation.

Modification in Surgical Plan following Intraoperative Detection of Co-existent Right Atrial Thrombus by Transesophageal Echocardiography in Chronic Constrictive Pericarditis

ABSTRACT Introduction Chronic constrictive pericarditis (CCP) is common in developing countries, tuberculosis being the most common cause. Dyspnea and congestive symptoms are the most common nonspecific presenting symptoms that require further evaluation for clinching the diagnosis. Coexistent right atrial (RA) thrombus and CCP are rare occurrences. Preoperative detection of RA thrombus is very important to avoid the risk of pulmonary thromboembolism during pericardiectomy or cannulation for establishing cardiopulmonary bypass (CPB). Perioperative echocardiography may play a crucial role in this setting. We report a case of CCP in which preoperative transesophageal echocardiography (TEE) detected RA thrombus that led to change in surgical plan and provided continuous monitoring during surgery. Case Report A 14-year-old male presented with a history of abdominal distension and pedal edema for 5 months. Physical examination revealed raised jugular venous pulse with normal heart sounds and no murmurs. Transthoracic echocardiography (TTE) revealed constrictive physiology and thickened pericardium. After induction of anesthesia, TEE revealed an irregular hyperechoic mass (50 × 36 × 30 mm) in the RA free wall that was not detected on preoperative TTE and computerized tomography (CT). Thickened pericardium all around mandated limited pericardiectomy under TEE guidance to allow bicaval cannulation for establishing CPB. This was followed by surgical removal of the thrombus and remaining pericardiectomy using CPB. His postoperative period was uneventful and the patient was discharged home on postoperative day 7. Conclusion The TEE may be instrumental in diagnosis of coexistent RA thrombus in the case of CCP resulting in major change in surgical plan and providing perioperative monitoring to avert significant morbidity and mortality. How to cite this article Ganesan R, Kumar B, Munirathinam GK, Bhat I, Mahajan S. Modification in Surgical Plan following Intraoperative Detection of Co-existent Right Atrial Thrombus by Transesophageal Echocardiography in Chronic Constrictive Pericarditis. J Perioper Echocardiogr 2017;5(1):34-37.

THE CONUNDRUM OF MANAGING A GIANT RIGHT ATRIAL THROMBUS

Right atrial (RA) thrombi have been described in patients with pacemaker leads. However, anti-coagulation therapy can be harmful in the case of a giant RA thrombus. Surgical extraction may be considered as an alternative treatment option. A 62-year-old lady with ischemic cardiomyopathy developed a

Umbilical venous catheter-related ischemia of fingers, right atrial thrombus treated with recombinant tissue plasminogen activator and lethal pulmonary hypertension in a preterm infant

We report the second case in English literature of limb ischemia related to umbilical venous catheter (UVC) use. This case was an extremely low birth weight preterm infant who otherwise remained stable during the first 8 days of life. On day 9, she developed intermittent ischemia of the distal phalanges of four fingers on the right hand. On day 11, the ischemia worsened during obtaining a blood for culture from the UVC. Blood cultures yielded cloxacillin-sensitive Staphylococcus aureus. On day 15, a large right atrial thrombus (RAT) was found after an echocardiogram (ECHO). Through consecutive ECHOs, we determined that the RAT was increasing in size. After administering a single dose of recombinant tissue plasminogen activator, size of the RAT decreased significantly, and no anticoagulants, it was deemed unnecessary. On day 147, the patient developed pulmonary hypertension (PH), which was attributed to severe bronchopulmonary dysplasia, and the patient died on day 168. After thorough analysis of the case, it is possible that PH might have been caused by a pulmonary embolism (PE). If a long-term anticoagulant was administered, or PE was considered and treated, the final patient outcome might have been different. In summary, a diagnosis of UVC-related ischemia requires a high index of suspicion. It may be of value to administer a long-term anticoagulant after successful treatment of RAT, and it would be prudent to consider a PE in a preterm infant who then develops PH.

Right Atrial Thrombus (RAT): Break It or Let It Be!! Either Way Hope for the Best

Right Atrial Thrombus (RAT): Break It or Let It Be!! Either Way Hope for the Best

Catheter extraction of high risk right atrial clot, technical tips, and lessons learned. successes and failures

Floating right atrial (RA) thrombus in the presence of intracardiac shunting, patent foramen ovale (PFO), or atrial septal defect is a complex clinical challenge. Surgical thrombectomy, thrombolytic therapy, and long‐term anticoagulation are all available management options. However, surgical therapy and thrombolytic therapy both carry significant inherent risk and there is lack of data to support adequacy and efficacy of long‐term anticoagulation. We report for the first time a case of a large free floating RA thrombus in the presence of a large PFO in a patient where surgical intervention and thrombolytic therapy were both felt to be contraindicated. A combined AngioVac thrombectomy procedure and a PFO closure were performed simultaneously and successfully without the fragmentation of the clot or the protrusion and migration of the clot systemically through the large PFO. A second case without the associated presence of a PFO is also being reported where the procedure failed to extract the thrombus. © 2013 Wiley Periodicals, Inc.

Early onset of cooling catheter–related right atrial thrombus following cardiac arrest

Catheter-related right atrial thrombus (RAT) is an uncommon life-threatening complication. Few cases of endovascular cooling catheter–related complications have been reported. We report the first case of endovascular cooling catheter–related RAT. A 17-year-old adolescent boy was treated with therapeutic hypothermia using an endovascular cooling catheter following ventricular fibrillation cardiac arrest. He became alert, but RAT was found 3 days after the placement of the cooling catheter. Anticoagulation with enoxaparin for 2 weeks completely resolved the RAT, and he was consequently treated with radiofrequency ablation and received an implanted cardiac defibrillator. This case report highlights the occurrence of endovascular cooling catheter–related RAT early after the placement of a catheter. Physicians should monitor whether RAT occurs during and following therapeutic hypothermia with a cooling catheter.

PP-130 RIGHT ATRIAL THROMBUS DERIVED FROM INFERIOR VENA CAVA AFTER LIVER TRANSPLANTATION

Introduction: Right­sided cardiac thrombi may develop due to secondary causes. Their incidence is very low and only a few case reports of right atrial (RA) thrombi exit in literature. Case Report: We report the case of a 56­year­old patient with orthotopic liver transplantation (OLT) about six months back, who was admitted to our clinic with symptoms of worsening chest pain and shortness of breath. Two and three­ dimensional transthoracic echocardiography (3DTTE) and transesophageal echocardiogram (TEE) showed a mobile right atrial thrombus 3.9×1.8 cm in size, traversing the right atrial cavity during the whole cardiac cycle. After one week of therapeutic anticoagulation, the thrombus began to shrink and after three weeks echocardiography confirmed no evidence of residual thrombus. Conclusion: In contrast to previously reported cases of massive RA thrombosis developing intraoperatively during OLT, in our case a RA thrombus developed six months after OLT. The right atrial thrombus was derived from inferior vena cava.

POSTER PRESENTATIONS

POSTER PRESENTATIONS

Massive Right Atrial Thrombus Due to Heparin-Induced Thrombocytopenia Type II

2 weeks after elective coronary artery bypass grafting, a 61-year-old male patient was admitted to the intensive care unit with severe acute dyspnea. The initial postoperative clinical course had been uneventful, however, at postoperative day 6, the patient had suffered a right hemispheric transient ischemic attack. Thus, high-dose heparin therapy was started and activated partial thromboplastin time carefully monitored within therapeutic levels. Since paroxysmal atrial fibrillation was present, a thromboembolic event was initially suspected. Transesophageal echocardiography revealed small residues of a thrombus within the left atrial appendage (Figure 1). Interestingly, a highly mobile massive right atrial (RA) thrombus was detected (Figure 2) which was in agreement with the CT scan demonstrating multiple pulmonary embolisms of the right pulmonary artery. Laboratory analysis revealed novel thrombocytopenia (27 platelets/nl) as compared to a normal preoperative platelet count (198 platelets/nl). These findings were consistent with the diagnosis of heparin-induced thrombocytopenia type II (HIT II). Therefore, heparin was immediately discontinued and replaced by the direct thrombin inhibitor lepirudin. The suspected HIT II was confirmed by positive heparin-induced platelet aggregation (HIPA test). Within 36 h after the cessation of heparin, the platelet count recovered (91 platelets/nl) without any further thromboembolic events. Subsequent transthoracic echocardiography demonstrated increasing mobility of the massive RA thrombus partially prolapsing into the right ventricle (Figure 3) with threatening fatal occlusion of the right ventricular outflow tract. The patient was immediately transferred to cardiosurgery for successful removal of the massive round-shaped RA thrombus. In summary, HIT II caused thromboem1 Department of Medicine II, Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.

Surgical Management of a Hemodialysis Catheter-Induced Right Atrial Thrombus

The placement of hemodialysis catheters are widely performed by vascular surgeons and surgical residents for use in both the hospital and the outpatient setting. Although long-term complications of this type of vascular access are relatively uncommon, an appreciation is warranted for the life-threatening complication of right atrial thrombus (RAT). Once recognized, medical or surgical management is mandatory to prevent further consequences from RAT. The optimal treatment for catheter-induced RAT is still controversial. Our case and review illustrates how the routine placement of a malpositioned hemodialysis catheter in a young man can lead to the serious complication of RAT that necessitated cardiac surgery after thrombolysis failed. We describe the successful surgical management of a hemodialysis catheter-induced RAT and suggest that in cases of large, mobile RATs with adherence to both atrial wall and catheter, suspicion or evidence of pulmonary embolus (PE), and low-risk surgical candidates, open thrombectomy may be an optimal and definitive treatment.

Right atrial thrombus in an asymptomatic hemodialysis patient with malfunctioning catheter and patent foramen ovale

The creation of an accurate functioning arteriovenous fistula has been a long-lasting problem in the hemodialysis setting. In spite of recent guidelines and largely because of the old age of the current dialysis population and a high incidence of diabetes mellitus, atherosclerosis, and related vascular problems, it is not always possible to create an adequate fistula. In that case, long-term tunneled indwelling central vein catheters are a frequently used alternative. Of the many possible complications related to venous access in hemodialysis patients, catheter dysfunction is the most prevalent. We report a 23-year-old female hemodialysis patient in whom such malfunctioning was followed by echocardiography that revealed a large right atrial thrombus (RAT) in close contact to the tip of a long-term indwelling catheter in the presence of a patent foramen ovale. Although RAT is a rare complication in hemodialysis patients, it has very specific therapeutic implications. The present patient underwent a successful surgical atrial thrombectomy. Our experience underscores that in cases of malfunctioning catheter, echocardiographic screening is mandatory.

Atrial thrombus and central venous dialysis catheters

A native arteriovenous fistula is the first choice for hemodialysis access. Despite improved catheter designs and the use of internal jugular veins, thrombotic complications still occur when tunneled central venous catheters are used as an alternative. Although right atrial thrombus (RAT) is a well-characterized complication of long-term central venous cannulation, particularly when used for parenteral nutrition and chemotherapy in pediatric practice, only 9 reported cases previously have been associated with the long-term use of central venous catheters for hemodialysis. We report five cases of RAT seen at our unit between 1994 and 1998 in patients who had been dialyzed using tunneled catheters. In four of five cases, the diagnosis was made during the investigation of hemoptysis or dyspnea. In the fifth case, a screening transthoracic echocardiogram revealed the thrombus. Three of five of the patients suffered pulmonary emboli, and a fourth patient had an unexplained electromechanical dissociation cardiac arrest without definite evidence of pulmonary embolus. Our experience suggests that anticoagulated patients with RAT remain at risk of pulmonary embolism. One of our patients successfully underwent atrial thrombectomy. In four of five of our cases and four of nine cases in the literature, the central venous catheter tip was within the right atrium. Positioning of the central venous catheter tip low down in the superior vena cava or in the right atrium has been advocated to improve dialysis adequacy and to reduce the incidence of catheter thrombosis. However, placement of the catheter tip within the right atrium may be associated with an increased risk of RAT. © 2001 by the National Kidney Foundation, Inc.

Tunneled Catheter-Associated Atrial Thrombi: Successful Treatment with Chronic Anticoagulation.

Tunneled dialysis catheter-associated right atrial thrombus (RAT) is a rarely reported complication. We reviewed hospital records of 10 patients from a teaching hospital dialysis unit, in whom RAT was diagnosed by trans-esophageal echocardiography (TEE). Patients were treated with chronic anticoagulation (heparin followed by warfarin) and followed over time. The group included 7 women; 6 patients were African American, 3 were Caucasian, and 1 was Hispanic. The average age was 52.1 ± 15.3 years. The most common presenting symptom was poor catheter flow on hemodialysis followed by fever and chills. On average, the patients had had 3.4 ± 2.7 catheter insertions before diagnosis of RAT, and the tunneled dialysis catheter (TC) had been in place for a mean of 91 ± 89.4 days when the thrombi were diagnosed. Trans-thoracic echocardiography (2-D echo) was done in 4 patients, but it identified RAT in only 1 patient. The catheter tip was at the junction of the superior vena cava and right atrium (SVC/RA) in most patients. Thrombolysis (unsuccessful) was attempted with urokinase in 3 patients, complicated in 2 patients by hemorrhage. After anticoagulation, 90% of the RAT resolved on repeated TEE. One patient had persistent RAT for 23 weeks and underwent surgical thrombolysis, but died postoperatively. We conclude that RAT is a frequently missed complication of a TC. Positioning the tip of the TC at the SVC/RA junction may not prevent RAT. Trans-esophageal echocardiography is a more sensitive diagnostic tool than 2-D echo and should be obtained early. Most patients can be successfully treated with anticoagulation alone. Thrombolytic therapy and surgical thrombolysis have high morbidity and mortality.