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 Table of Contents  
INTERESTING CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 3  |  Page : 182-184

An unusual case of right atrial mass


Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Date of Web Publication10-Dec-2018

Correspondence Address:
Dr. Chetana Krishnegowda
Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar 9th Block, Bannerghatta Road, Bengaluru - 560 069, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_27_18

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  Abstract 

Imaging modalities are invaluable noninvasive tools in identifying and diagnosing intracardiac masses. However, it is not always easy to differentiate one from the other. Here, we report an unusual case of right atrial mass in a 54-year-old man presenting with atypical chest pain, in whom despite the multimodal approach, the histopathology study was the one that gave us the definitive diagnosis.

Keywords: Echocardiography, intracardiac mass, right atrial mass, right atrial myxoma, right atrial thrombus


How to cite this article:
Krishnegowda C, Ramalingam R, Subramanyam K, Palakshachar A, Cholenahally MN, Moorthy N. An unusual case of right atrial mass. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:182-4

How to cite this URL:
Krishnegowda C, Ramalingam R, Subramanyam K, Palakshachar A, Cholenahally MN, Moorthy N. An unusual case of right atrial mass. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2018 [cited 2019 Mar 19];2:182-4. Available from: http://www.jiaecho.org/text.asp?2018/2/3/182/247029




  Introduction Top


Intracardiac masses most commonly encountered include primary and metastatic tumors, thrombus, and vegetation.[1] Early detection and accurate diagnosis of intracardiac masses have important therapeutic and prognostic implications. Timely surgical intervention is crucial in resolving the diagnostic dilemma in enigmatic right atrial (RA) masses.


  Clinical Presentation Top


A 52-year-old male presented with atypical chest pain of 4 days duration. History was significant for cerebrovascular accident 3 years back. The patient was in sinus rhythm with the S1Q3T3 pattern on electrocardiography [Figure 1]. On examination, heart rate was 98/min, SpO2 96% and cardiac auscultation were unremarkable. Transthoracic and transesophageal echocardiogram (TEE) revealed a huge RA mass measuring 4.3 cm × 3.6 cm freely floating from RA to the right ventricle (RV) across the tricuspid valve (TV) with no attachments visualized [[Figure 2], [Figure 3], [Figure 4] and Videos 1-4]. His cardiac computed tomography (CT) scan showed RA and RV dilatation without any structural abnormalities of RA, RV, or TV and heterogenous filling defect in RA and RV. Coronaries appeared normal, and there was no evidence of pulmonary embolism by CT [Figure 5]. Our patient underwent surgery and an oval, pedunculated mass was excised from the RA [Figure 6]. The gross specimen of the mass with a stalk was suggestive of a myxoma but the mass was well defined and firm in consistency unlike myxomas which are usually friable and gelatinous [Figure 7] and [Figure 8]. Histopathology, however, reported as an organized thrombus without any evidence of myxoma cells [Figure 9]a, [Figure 9]b, [Figure 9]c confirmed by two cardiac pathologists. Postoperative course of the patient was uneventful and was discharged without complications.
Figure 1: Electrocardiogram showing McGinn White sign (S1Q3T3 pattern) suggestive of acute right heart strain

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Figure 2: Trans-esophageal echocardiogram image showing RA mass measuring 4.23 cm x 2.51 cm in four chamber view

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Figure 3: Bicaval view of the RA mass on TEE imaging. RA: Right atrium, TEE: Trans-esophageal echocardiogram

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Figure 4: AV short axis view of RA mass on TEE imaging. RA: Right atrium, TEE: Trans-esophageal echocardiogram, AV: Aortic valve

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Figure 5: Cardiac computed tomography scan demonstrating right atrial and right ventricular dilatation without any structural abnormalities and heterogeneous filling defect in the right atrium and right ventricle

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Figure 6: Intraoperative image of RA mass excision. RA: Right atrium

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Figure 7: Surgically excised right atrial mass along with the avulsed pedicle

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Figure 8: Longitudinal cut section of the right atrial mass

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Figure 9: (a-c) Histopathology sections showing platelet rich fibrin thrombus with entrapped red blood cells and areas of hyalinisation and fibroblastic proliferation suggestive of organised thrombus

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  Discussion Top


Cardiac masses, in general, can be due to either tumor (primary or secondary), thrombus or vegetation. Primary cardiac tumors are rare while secondary tumors are 20–40 times more common than primary tumors. Myxoma, a benign tumor, is the most common type of primary cardiac tumor.[2] The commonest site of myxoma is in left atrium (75%) followed by right atrium (18%) and more rarely in aorta, pulmonary artery, ventricles vena cava or even in another organ.[3] The clinical presentation for cardiac tumors is quite varied, but it is dependent upon tumor location and size, rather than upon histologic characteristics. The classical triad of intracardiac obstruction to blood flow, thromboembolic events, and constitutional symptoms are pathognomic of myxoma. RA myxoma, in particular, can obstruct TV, causing signs and symptoms of right heart failure and syncope.[4]

Patients with mechanical valves, pacemaker leads, ventricular or atrial septal closure devideovices, and indwelling central venous lines are at higher risk for RA thrombi. RA thrombus has been described in about 10% of patients with PTE. Of patients with RA thrombi, 36% had pulmonary emboli, and 6.5% of all patients with PTE confirmed at autopsy had RA thrombi.[5]

In our case, considering the absence of atrial fibrillation, catheter use, and pulmonary embolism, the RA mass we thought was most probably a myxoma. However, the absence of constitutional symptoms, unusual location in the RA without any septal attachment seen on imaging pointed against the diagnosis of myxoma.

Echocardiography remains the best noninvasive diagnostic tool for intracardiac masses. Many times echocardiographic features of a calcified ball valve thrombus can masquerade as a calcified myxoma and viceversa. Oliveira et al. reported that transthoracic echocardiography alone is 95% sensitive in detecting myxomas and the sensitivity increases to 100% when followed by transesophageal echocardiography. CT and magnetic resonance imaging (MRI) are useful to demonstrate the point of fixation and other complications.[6]

Calleja et al. presented a rare case of soft-tissue fibrosarcoma of the shoulder with an RA mass on TTE and showed contrast enhancement on TEE suggesting intracardiac metastasis. Interestingly, RA mass completely resolved with anticoagulation therapy confirming a diagnosis of thrombus rather than a tumor.[7]

Rangel-Herna × ndez et al. have reported an unusual case of RA mass in a patient undergoing hemodialysis. MRI showed a mobile oval mass in the right atrium, attached to its floor, adjacent to the inferior vena cava outlet, with suggestive features of myxoma. However, histopathology confirmed the mass to be an infected thrombus.[8]


  Conclusion Top


Therefore, multimodal imaging should be performed undoubtedly to identify the intracardiac mass and delineate the adjacent structures. However, to arrive at the correct diagnosis, we need to integrate clinical syndrome, clues from various imaging modalities such as regional location, mass morphology and wave with the valve excursion. Timely surgical intervention as in our case is the mainstay of management of RA masses to prevent possible fatal consequences such as sudden death.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pietro DA, Parisi AF. Intracardiac masses. Tumors, vegetations, thrombi, and foreign bodies. Med Clin North Am 1980;64:239-51.  Back to cited text no. 1
    
2.
Libby P, Bonow RO, Mann DL, Zipes DP, editors. BRAUNWALD's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, PA: Saunders Elsevier; 2008.  Back to cited text no. 2
    
3.
Croti UA, Braile DM, Souza AS, Cury PM. Right ventricle and tricuspid valve myxoma. Rev Bras Cir Cardiovasc 2008;23:142-4.  Back to cited text no. 3
    
4.
Rathor DKS, Jhajhria NS, Gupta VK. Atypical clinical presentation of right atrial myxoma: A case report. Int Surg J 2017;4:1444-6.  Back to cited text no. 4
    
5.
Benjamin MM, Afzal A, Chamogeorgakis T, Feghali GA. Right atrial thrombus and its causes, complications, and therapy. Proc (Bayl Univ Med Cent) 2017;30:54-6.  Back to cited text no. 5
    
6.
Oliveira R, Branco L, Galrinho A, Abreu A, Abreu J, Fiarresga A, et al. Cardiac myxoma: A 13-year experience in echocardiographic diagnosis. Rev Port Cardiol 2010;29:1087-100.  Back to cited text no. 6
    
7.
Calleja AC, Alharthi MS, Khandheria BK, Chaliki HP. Contrast-enhanced right atrial mass: Tumour or thrombus? Eur J Echocardiogr 2009;10:365-6.  Back to cited text no. 7
    
8.
Rangel-Hernaández MA, Aranda-Fraustro A, Melendez-Ramirez G, Espıánola-Zavaleta N. Misdiagnosis for right atrial mass: A case report. Eur Heart J Case Rep 2018;2:1-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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