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 Table of Contents  
INTERESTING CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 75-77

Unusual Echocardiographic Diagnosis of a Metastatic Thrombus - A Case Report


1 Department of Anesthesiology and Palliative Care, Cancer Institute (WIA), Chennai, Tamil Nadu, India
2 Department of Anesthesia, Cancer Institute (WIA), Chennai, Tamil Nadu, India

Date of Submission13-Jul-2020
Date of Acceptance13-Aug-2020
Date of Web Publication05-Apr-2021

Correspondence Address:
Dr. Nivedhyaa Srinivasaraghavan
B-1, SDS Pearl, Ajantha Avenue, Venkatesapuram, Kottivakkam, Chennai - 600 041, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_32_20

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  Abstract 

Renal cell carcinoma has high propensity for intravascular and lymphatic spread. In one percent of such cases, tumor can reach up to the right atrium. This case reports the postoperative tumor embolization in a patient with renal cell carcinoma. An elderly female underwent a left radical nephrectomy and inferior vena cava (IVC) thrombectomy. She developed atrial fibrillation on the sixth postoperative day following the surgery in the postoperative unit. A bedside transthoracic echocardiogram detected a migrating echo dense structure moving across the tricuspid valve. Following this, she underwent an urgent right atriotomy and extraction of the tumor thrombus through cardiopulmonary bypass. The occurrence of atrial fibrillation in this patient with renal cell cancer in the postoperative period could have possibly been trigerred by a tumor thrombus in the right atrium.

Keywords: Atrial fibrillation, atriotomy, intracardiac thrombus, renal cell cancer, transesophageal echocardiogram, transthoracic echocardiogram


How to cite this article:
Srinivasaraghavan N, Balakrishnan K, Venketeswaran MV, Chockalingam P. Unusual Echocardiographic Diagnosis of a Metastatic Thrombus - A Case Report. J Indian Acad Echocardiogr Cardiovasc Imaging 2021;5:75-7

How to cite this URL:
Srinivasaraghavan N, Balakrishnan K, Venketeswaran MV, Chockalingam P. Unusual Echocardiographic Diagnosis of a Metastatic Thrombus - A Case Report. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2021 [cited 2021 Jul 23];5:75-7. Available from: https://www.jiaecho.org/text.asp?2021/5/1/75/313086


  Introduction Top


Intraoperative tumor embolization in renal cell carcinoma is a rare phenomenon although reported and associated with high incidence of mortality.[1] Along similar lines, few cases of pulmonary emboli have been reported in the postoperative period after radical nephrectomy and inferior vena cava (IVC) thrombectomy.[2] While it is true that an intraoperative tumor thrombus could be detected using a transesophageal echocardiogram (TEE), the same may not be feasible in the postoperative period.[3]


  Case Report Top


A 69-year-old female, with no associated illness, underwent left nephrectomy, and IVC thrombectomy for renal cell carcinoma with a thrombus extending from the left renal vein to the infra-hepatic segment of IVC as shown in the preoperative imaging of the patient [Figure 1].
Figure 1: Preoperative imaging: (a) Positron emission tomography/coronal plane shows uptake in the inferior vena cava, left renal vein, and left kidney (squared area). (b) Contrast computed tomography/axial plane shows thrombosis of left renal vein (green arrow) and inferior vena cava (blue arrow)

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She had an intraoperative blood loss of 2500 ml and was transfused with 1200 ml of packed red cell and 300 ml of fresh frozen plasma.

The patient was asymptomatic postoperatively except for a persistently low platelet count ranging between 25,000 cells mm−3 and 55,000 cells mm−3 due to which anticoagulant medications were withheld. Transthoracic echocardiograms (TTE) performed in this patient in the preoperative period and on the 2nd postoperative day were unremarkable. The patient complained of chest pain on the 6th postoperative day. A 12 lead electrocardiogram detected an atrial fibrillation with a heart rate of 160–180/min. Her blood pressure was 126/80 mmHg with a mean arterial pressure of 93 mmHg. An intravenous bolus of 150 mg of amiodarone was given over 10 min. Sinus rhythm was achieved after 30 min. A bedside TTE revealed a big round echo dense structure freely moving between the right atrium and right ventricle across the tricuspid valve [Video 1] and [Figure 2].
Figure 2: (a) An apical view of transthoracic echocardiogram of the patient with an echo dense thrombus in the right atrium. The thrombus in the right ventricle as in (b) (white arrow points to the thrombus). LA: Left atrium, LV: Left ventricle, RA: Right atrium, RV: Right ventricle

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Video legends

Video 1: Shows the thrombus moving between the right atrium and right ventricle in the four chamber view captured with TTE at the apex.

[Additional file 1]

The patient was shifted to operation theatre emergently and a thrombus was extracted from the right atrium with cardiopulmonary bypass support [Figure 3]. Histopathological examination of the thrombus was consistent with metastatic renal cell cancer.
Figure 3: Two subfigures. (a) The intraoperative transesophageal echocardiogram RV inflow outflow view with the thrombus in the RA. (b) The tumor thrombus retrieved. Ao: Aortic valve, RA: Right atrium, RV: Right ventricle

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  Discussion Top


An intracardiac echo dense structure can have multiple differential diagnoses which include a thrombus, tumor embolus from the renal cell carcinoma, an atrial myxoma, any other cardiac or metastatic tumor, vegetation, etc.

Patients with intracardiac tumors may present with hemodynamic instability due to ventricular outflow obstruction, embolism, or electrical dysfunction of the heart or a cerebrovascular accident.[4],[5] Cardiac involvement in renal cell carcinoma can arise as direct extension of the vascular tumor thrombus through the IVC into the right atrium or by embolic dissemination into the heart. We hypothesize that the new onset atrial fibrillation which manifested as chest pain in our patient was due to the tumor migration into the atrium. Whether the movement of the thrombus caused the fibrillation or the fibrillation caused the thrombus to move across tricuspid valve is indeed a thought to ponder.

The probable cause of atrial fibrillation in this scenario could be attributed to the disturbance in the atrial architecture due to the thrombus, increased left atrial pressure, systemic inflammation, or senility.[6],[7],[8]

Intraoperative use of TEE during nephrectomy for renal cell cancer has been recommended in a few cases to detect intracardiac thrombus or pulmonary emboli at the earliest.[3] TEE has also been used in real-time visualization of the thrombus in the IVC, to clamp the IVC above the thrombus and in confirmation of complete removal of the thrombus during radical nephrectomy.[9] TEE is the gold standard intraoperative diagnostic tool for identifying atrial thrombus especially of the left atrial appendage, however a thrombus at the left ventricular apex may be missed by a TEE. The argument that an intraoperative use of TEE may have detected the presence of residual intracardiac or vena caval tumor in this patient is weakened by the fact that the patient was hemodynamically stable until the 6 day after surgery. One persistent debate in view of the identified thrombus was whether it was a tumor dislodgement during surgery or that of a metastatic thrombus from the suprahepatic region of IVC traversing to the atrium. We believe that the intracardiac thrombus is a new occurrence in this patient because the echocardiogram in the immediate postoperative period was normal. Screening of IVC above the level of the renal vein was not performed in the postoperative period for any residual thrombus as our patient was asymptomatic except for thrombocytopenia which we attributed to sepsis.[10] TTE detected the intracardiac thrombus in this patient probably because of the relatively large size (postoperative measurement of the thrombus being 5 cm × 6 cm [Figure 3].


  Conclusion Top


In the postoperative period, new onset atrial fibrillation deserves a meticulous search for the precipitating factors. Especially in the setting of renal cell cancer, a TTE will be particularly useful in visualizing an intracardiac tumor thrombus.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Galvez JA, Clebone A, Garwood S, Popescu WM. Fatal intraoperative cardiac thrombosis in a patient with renal cell carcinoma. Anesthesiology 2011;114:1212.  Back to cited text no. 1
    
2.
Wang KR. Massive postoperative pulmonary artery tumor embolism from renal cell carcinoma. Anesthesiology 2014;120:481.  Back to cited text no. 2
    
3.
Ahmed MM, Al-Najjar M, Aftab M, Anton JM, Colen JS, Reul RM. Early detection of a cavo-pulmonary tumor embolus with the use of transesophageal echocardiography. Tex Heart Inst J 2015;42:66-9.  Back to cited text no. 3
    
4.
Ansari J, Alhelali S, Albinmousa Z, Farrag A, Ali AM, Abdelgelil M, et al. Rare case of intracardiac renal cell carcinoma metastasis with response to nivolumab: Case report and literature review. Case Reports in Oncology. Basel: S. Karger AG; 2018. p. 861 70.  Back to cited text no. 4
    
5.
Habash F, Vallurupalli S. Challenges in Management of Left Ventricular Thrombus. Therapeutic Advances in Cardiovascular Disease. UK: SAGE Publications Ltd.; 2017. p. 203-13.  Back to cited text no. 5
    
6.
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 2071-104.  Back to cited text no. 6
    
7.
Kistler PM, Sanders P, Fynn SP, Stevenson IH, Spence SJ, Vohra JK, et al. Electrophysiologic and electroanatomic changes in the human atrium associated with age. J Am Coll Cardiol 2004;44:109-16.  Back to cited text no. 7
    
8.
Harada M, Wagoner DR, Nattel S. Role of inflammation in atrial fibrillation pathophysiology and management. Circul J 2015;79:495-502.  Back to cited text no. 8
    
9.
Oikawa T, Shimazui T, Johraku A, Kihara S, Tsukamoto S, Miyanaga N, et al. Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma. Int J Urol 2004;11:189-92. Available from: http://doi.wiley.com/10.1111/j. 1442-2042.2003.00780.x. [Retrieved 2019 Dec 03].  Back to cited text no. 9
    
10.
Kusuyama T, Iida H, Takeshita H, Wake R, Shimodozono S, Kanamitsu H, et al. Patient with a massive idiopathic thrombosis in the inferior vena cava. Ann Vasc Dis 2012;5:89-91.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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